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Digitized  by  the  Internet  Arciiive 

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DISEASES    OF    THE    EYE. 


PRACTICAL    TREATISE 

t 


DISEASES    OF    THE    EYE. 

By  WILLIAM  MACKENZIE, 
//> 

LECTURER    ON    THE    EYE    IN    THE    UNIVERSITY    OF    GLASGOW,    AND    ONE    OF    THE    SUR- 
GEONS   TO    THE    GLASGOW    EYE    INFIRMARY. 


FROM  THE  LAST  LONDON  EDITION. 


BOSTON: 

CARTER,    HENDEE    AND    CO 

J.  E.  Hinckley  &  Co.,  Printers,  14  Water  Street. 

""i'833""" 


M  11 


'   -^    -     >.  \ 


»    •\      :'■*-    \  V 


CONTENTS. 


Chapter  I.     Diseases  of  the  Orbit, 
Section  I.  Injuries  of  the  Orbit, 


11. 
Ill 


IV. 


•            •            •         .  *^- 

1.  Contusions  and  Cuts  upon  the  Edge  of  the  Orbit,  2 

9.  Fractures  of  the  Edge  of  the  Orbit,             .  3 
y.  Fractures  of  the   Walls  of  the   Orbit,  attending 

Fractured  Skull,             ...  4 

4.  Counter-Fractures  of  the  Orbit,                 .  5 

5.  Penetrating  Wounds  of  the  Walls  of  the  Orbit,  ib. 

6.  Incised  Wounds  of  the  Orbit,         .            .  16 

7.  Gunshot  Wounds  of  the  Orbit,  .  .  17 
Periostitis,  Ostitis,  Caries,  and  Necrosis  of  the  Orbit,  26 
Periostosis,  Hyperostosis,  Exostosis,  and  Osteo-Sar- 

coma  of  the  Orbit,      ....  35 

1.  Periostosis  of  the  Orbit,     .            •            .  ib. 

2.  Hyperostosis  of  the  Orbit,               .            .  36 

3.  Exostosis  of  the  Orbit,       ...  37 

4.  Osteo-Sarcoma  of  the  Orbit,  .  .  47 
Dilatation,  Deformation,  and  Absorption  of  the  Orbit, 

from  Pressure,           ....  49 

1.  Pressure  on  the  Orbit  from  within  the  Orbit,  51 

2.  Pressure  on  the  Orbit  from  the  JVostril,  ib. 

3.  Pressure  on  the  Orbit  from  the  Frontal  Sinus,  55 

4.  Pressure  on  the  Orbit  from  the  Maxillary  Sinus,  62 

5.  Pressure  on  the  Orbit  from  the  Sphenoid  Sinus,  69 

6.  Pressure  on  the  Orbit  from  the  Cavity  of  the  Cra- 

nium,     .             .             .             .             '  ib. 


Chapter  II.     Diseases  of  the  Secretij^g  Lacrymal  Organs,  73 

Section            I.  Injuries  of  the  Lacrymal  Gland  and  Ducts,      .  ib. 
II.  Xeroma,             .            -            .            .            .74 

III.  Epiphora,           .....  75 

IV.  Inflammation  and  Suppuration  of  the  Lacrymal 

Gland, 76 

V.  Enlargement  or  Scirrhus  of  the  Lacrymal  Gland,  78 

VI.  Lacrymal  Tumour  in  the  Lacrymal  Gland,      .  86 
VII.  Lacrymal  Tumour  in  the  Subconjunctival  Cellular 

Membrane,    .....  92 

VIII .  True  Lacrymal  Fistula,            ...  94 

IX.  Morbid  Tears,                ....  ib. 

X.  Lacrymal  Calculus,       .  *         .            .            .  95 

Chapter  III.    Diseases  of  the  Eyebrow  and  Eyelids,       .  97 

Section            I.  Injuries  of  the  Eyebrow  and  Eyelids,               .  ib^ 

1.  Contusion  and  Ecchymosis,           .            .  ih. 

2.  Burns  and  Scalds,             ...  98 

3.  Incised  and  Lacerated  Wounds,    .            .  100 


VI 

Section  II.  Phlegmonous  Inflammation  of  the  Eyelids, 

III.  Erysipelatous  Inflammation  of  the  Eyelids, 

IV.  Carbuncle  of  the  Eyelids, 
V.  (Edema  of  the  Eyelids, 

VI.  Emphysema  of  the  Eyelids, 
VII.  Inflammation  of  the  Edges  of  tlie  Eyelids,  or  Oph- 
thalmia Tarsi,  .... 
VIII.  Hordeolum  and  Grando, 
IX.  Phlyctenula  and  Milium, 
X.  Warts  on  the  Eyelids, 

XI.  Encysted  Tumours  of  the  Eyelids,  and  Eyebrow, 
XII.  Callosity  of  the  Eyelids, 

XIII.  Cancer  of  the  Eyelids, 

XIV.  Syphilitic  Ulceration  of  the  Eyelids,     . 

XV.  Naevus  Maternus,   and  Aneurism  by  Anastomosis 

of  the  Eyelids,  .... 

XVI.  Neuralgia,  or  Tic  Douloureux, 
XVII.  Twitching  or  Quivering  of  the  Eyelids, 
XVIII.  Morbid  Nictitation, 
XIX.  Photophobia,  and  Spasm  of  the  Eyelids, 
XX.  Palsy  of  the  Orbicularis  Palpebrarum, 
XXI.  Ptosis,  or  Falling  down  of  the  Upper  Eyelid, 

1.  Mechanical  Ptosis, 

2.  .Atonic  Ptosis,        .  •  .  . 

3.  Paralytic  Ptosis, 

XXII.  Lagophthalmos,  and  Retraction  of  the  Eyelids, 

XXIII.  Ectropium,  or  Eversion  of  the  Eyelids, 

1.  Eversion  of  either  Lid,  from  Inflammation  and 

Strangulation     .... 

2.  Eversion  of  Lower  lAd,  from  Relaxation, 

3.  Eversion  of  Lower  Lid,  from  Excoriation, 

4.  Eversion  of  Lower  Lid,  from  Disunion  at  the 

Temporal  Angle  of  the  Lids, 

5.  Eversion  of  either  Lid,  from  a  Cicatrice,   . 

6.  Eversion  from  Caries  of  the   Orbit, 

XXIV.  Trichiasis  and  Distichiasis, 

XXV.  Entropium,  or  Inversion  of  the  Eyelids, 
XXVI.  Phtheiriasis,        ..... 
XXVII.  Madarosis, 

Chapter  IV.  Diseases  or  the  Tu>"ica  Co>'juxctiva, 

Section  1.  Injuries  of  the  Conjunctiva,  and  Foreign  Sub- 

stances in  its  Folds, 
II.  Subconjunctival  Ecchymosis, 

III.  Subconjunctival  Emphysema, 

IV.  Subconjunctival  Phlegmon, 

V.  Pterygium, 
VI.  Conjunctiva  Arida, 

VII.  Fungus  of  the  Conjunctiva, 
VIII.  Warts  of  the  Conjunctiva, 
IX.  Tumours  of  the  Conjunctiva, 

Chapter.  V.  Diseases  of  the'Semilunar  Membrane  and  Carujs'- 

CULA  LaCRYMALIS, 

Section  I.  Inflammation  of  the  Semilunar  Membrane  and 

Caruncula  Lacrymalis, 
II.  Encanthis,  ..... 


Chapter  VI.  Diseases  of  the  Excreting  Lacrymal,  Organs,  171 


Section  I.  Injuries  of  the  Excreting  Lacrymal  Organs, 

1.  Injuries  of  the  Lacrymal  Canals, 

2.  Injuries  of  the  hacrymal  Sac, 

3.  Injuries  of  the  JVasal  Duct, 

II.  Acute  Inflammation  cf  the  Excreting  Lacry- 

mal Organs, 

III.  Chronic  Blenorrhoea  of  the  Excreting  Lacry- 

mal Organs, 

IV,  Stillicidium  Lacrymarum, 

V.  Fistula  of  the  Lacrymal  Sac, 

VI.  Caries  of  the  Os  Unguis, 

VII.  Relaxation  of  the  Lacrymal  Sac, 
VIII.  Mucocele  of  the  Lacrymal  Sac, 

IX.  Obstruction  of  the  Puncta  Lacrymalia  and 

Lacrymal  Canals, 
X.  Obstruction  of  the  Nasal  Duct, 

Chapter  VII.  Diseases  oe  the  Muscles  of  the  Eyeball. 

Section  I.  Injuries  of  the  Muscles  of  the  Eyeball, 

II.  Palsy  of  the  Muscles  of  the  Eyeball,     . 

III.  Double  Vision  from  want  of  Correspondence 

in  the  Action  of  the  Muscles  of  the 
Eyeball,  .... 

IV.  Strabismus,        .... 
V.  Luscitas,  -^r  Immovable  Distortion  of  the 

Eyeball, 

VI.  Oscillation  of  the  Eyeball, 

VII.  Nystagmus,        .... 

VIII.  Tetanus  Oculi, 


ib. 

ib. 

ib. 

172 

ib. 

177 
184 

185 
188 
189 
191 

193 
195 

202 

ib. 
203 


204 
205 

211 
212 
212 

ib. 


Chapter  VIII.  Diseases  in  the  Orbital  Cellular  Membrane,  ib. 

Section           I.  Inflammation  of  the  Orbital  Cellular  Mem- 
brane,             .             .             .             .             .  ib. 
II.  Infiltration  of  the  Orbital  Cellular  Membrane,  217 

III.  Scirrhus  of  the  Orbital  Cellular  Membrane,      .  219 

IV.  Steatomatous  and  Encysted  Tumours  in  the 

Orbit,_        _ ib. 

1.  Extirpation  of  Steatomatous  Tumours,      .  221 

2.  Puncture  of  Encysted  Tumours,               .  229 

3.  Partial  Extirpation  of  Encysted  Tumours,  232 

4.  Total  Extirpation  of  Encysted  Tumours,  235 
V.  Orbital  Aneurisms,         ....  240 

1.  Orbital  Aneurism  by  Anastomosis,             .  ib. 

2.  Aneurism  of  the  Ophthalmic  .Artery,          .  247 

Chapter  IX.  Injuries  of  the  Eyeball,              .            .            .  248 

Section            I.  Injuries  of  the  Cornea,               .            .            .  ib. 

1.  Contusion  of  the  Cornea,  .            .            .  ib. 

2.  Foreign  Substances  adhering  to  the  Cornea,  ib. 

3.  Foreign  Substances  imbedded  in  the  Cornea,  ib. 

4.  Punctured  Wounds  of  the  Cornea,            .  251 

5.  Penetrating  Wounds  in  the  Cornea — Loss  of 

the  Aqueous   Humour — Prolapsus  of  the 

Ms,          .....  252 


VIU 


6.  Burns  of  the  Cornea, 
Section  II.  Injuries  of  the  Iris,        .... 

III.  Injuries  of  the  Crystalline  Lens  and  Capsule, 

IV.  Wounds  of  the  Sclerotica  and  Choroidea, 
V.  Pressure  and  Blows  on  the  Eye, 

VI.  Gunshot  Wounds  of  the  Eye, 
VII.  Dislocation  of  the  Eyeball, 
VIII.  Evulsion  of  the  Eyeball, 

Chapter  X.     The  Ophthalmia,  or  I>'rLAMMATORY  Diseases  of  the 

Eye, 261 


Section 


I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 


IX. 
X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 

XIX. 

XX. 

XXI. 

XXII. 

XXIII. 

XXIV. 

XXV. 

XXVI. 

XXVII. 

XXVIII. 

XXIX. 


The  Ophthalmise  in  general, 
Remedies  for  the  Ophthalmias, 
Conjunctivitis  in  general, 

Puro-mucous  Conjunctivitis  in  general 

Catarrhal  Ophthalmia, 

Contagious  Ophthalmia, 

Ophthalmia  of  Xew-born  Children, 

Gonorrhceal  Ophthalmia, 

1.  From  Inoculation, 

2.  From  Metastasis, 

3.  Without  Inoculation  or  Metastasis 
Scrofulous  Ophthalmia, 
Erysipelatous  Ophthalmia, 
Variolous  Ophthalmia, 
Morbillous  and  Scarlatinous  Ophthalmias, 
Rheumatic  Ophthalmia, 
Catarrho-rheumatic  Ophthalmia, 
Scrofulous  Corneitis, 
Iritis  in  general. 
Rheumatic  Iritis, 
Syphilitic  Iritis, 
Pseudo-syphilitic  Iritis, 
Scrofulous  Iritis, 
Arthritic  Iritis, 
Choroiditis, 
Retinitis, 
Aquo-capsulitis, 
Inflammation  of  the  Crystalline  Lens  and  Cap; 
Inflammation  of  the  Hyaloid  Membrane, 
Traumatic  Ophthalmias, 
Compound  Ophthalmise, 
Intermittent  Ophthalmise, 


;ule. 


Chapter  XI.     Diseases  coxseque>t  to  the  Ophthalmia, 

Section  I.  Onyx,  or  Abscess  of  the  Cornea, 

II.  Hypopium, 

III.  Ulcers,  Dimple,  Hernia,  and  Fistula  of  the  Cornea, 

and  Hernia  of  the  Iris, 

IV.  Specks,  or  Opacities  of  the  Cornea, 

1.  .Yebula, 

2.  Albugo,      . 

3.  Leucoma, 
V.  Granular  Conjunctiva, 

VI.  Anchylo-blepharon  and  Sym-blepharon, 
VII.  Synechia, 
Vin.  Obliteration  of  the  Pupil, 


IX 


Section        IX.  Cataracts,  or  Specks  of  the  Crystalline  Capsule  and 
Lens,  ..... 

X.  Dissolution  of  the  Vitreous  Humour, 
XI.  Atrophy  of  the  Eye,      .... 
XII.  Staphyloma,       ..... 

1.  Staphyloma  of  the  Iris,  or   Staphyloma  Race- 

mosum,  .... 

2.  Staphyloma  of  the  Cornea  and  Iris, 

3.  Staphyloma  of  the  Choroid  and  Sclerotica, 
XIII.  Varicosity  of  the  External  and  Internal  Vessels  of 


the  Eye, 

XIV.  Amaurosis,        ..... 
XV.  Ossification  in  different  Parts  of  the  Eye, 
1.  Ossification  of  the  Cornea, 
2    Osseous  Deposite  in  the  Anterior  Chamber, 

3.  Ossification  of  the  Choroid  Coat, 

4.  Ossification  of  the  Retina, 

5.  Ossification  of  the  Hyaloid  Membrane,  Crystal- 

line Capsule,  and  Crystalline  Lens, 

Chapter  XII.    Adaptation  of  an  Artificial  Eye, 


421 
422 

ib. 
ib. 

ib, 
423 
42» 

ib. 
430 

ib. 

ib. 

ib. 
431 
432 

ib. 
433, 


Chapter  XIII.    Partial  and  General  Enlargements  of  the  Eye- 
ball ;  Effusions  and  Tumours  within  its  Coats,  437 

Section           I.  Conical  Cornea,            ....  ib.. 

II.  Hydrophthalmia,  or  Dropsy  of  the  Eye,           .  440 

1.  Dropsy  of  the  Aqueous  Humour,               .  441 

2.  Sub-sclerotic  Dropsy,        ^            .            .  442 

3.  Suh-choroid  Dropsy,          .            .            .  ib.^ 

4.  Dropsy  of  the  Vitreous  Humour,               ,  444 

5.  General  Hydrophthalmia,              .            .  445 

III.  Sanguineous  Effusion  into  the  Eye,     .            .  446 

IV.  Fungous  Excrescence  of  the  Iris,        .            .  450 
V.  Scirrhus  of  the  Eyeball,            .            .            .  451 

VI.  Spongoid  or  Medullary  Tumour  of  the  Eyeball,  453 

VII.  Melanosis  of  the  Eyeball,         ...  459 

Vm.  Extirpation  of  the  Eyeball,        ...  469 

Chapter  XIV.    Cataract,          .....  471 

Section  I.  Definition  and  Diagnosis  of  Cataract;  Method  of 

Examining  Cases  of  this  Disease ;  Causes  and 

Prognosis,     .....  i6, 

II.  Genera  and  Species  of  Cataract,          .            .  480 

Class       I.  True  Cataracts,       .            .            .  481 

Genus     I.  Lenticular  Cataract,     .            .  ib. 

Genus    II.  Capsular  Cataract,        .            .  ib. 

Species  1.  Anterior  Capsular  Cataract,           .  ib. 

Species  2.  Posterior  Capsular  Cataract,          .  482 

Genus     III.  Morgagnian  Cataract,            .  483 

Genus     IV.  Capsulo-Lenticular  Cataract,  ib. 

Species  1.  Central  Capsulo-Lenticular  Cataract,  ib. 

Species  2.  Common  Capsulo-Lenticular  Cataract,  484 

Species  3.  Cystic  Capsulo-Lenticular  Cataract,  485 

Species  4.  Siliquose  Capsulo-Lenticular  Cataract,  ib. 

Species  5.  Bursal  Capsulo-Lenticular  Cataract  486 

Class           II.  Spurious  Cataracts,            .            .  ib. 

Genus          I.  Fibrinous  Cataract,            .           ,  ib. 


Species  1.  Floccvlent  Fihnnoua  Cataract,  4t6 

Species  2.  Clotted  Fibrinous  Cataract,            .  487 

Species  3.     Trabecular  Fibrinous  Cataract,  i/*. 

Genus        II.  Purulent  Cataract,  .            •  ib. 

f                              Genus       III.  Sanguineus  Cataract,           .  ib. 

Genus       IV,  Pigmentous  Cataract,           ._  488 

ill.  Various  additional  Classifications  and  Distinctions 

of  Cataract,              ....  i&. 

I                                  1.  Consistence,         .            .            .            •  ib- 

2.  Size, 489 

3.  Colour,                 .            .            .            .  ib. 

4.  Duration  and  Development,         .            .  ib- 

5.  Curability,           ....  490 
IV.  Complications  of  Cataract,         .            .            •  ib. 

V.  Treatment  of  Cataract  without  Operation,        •  492 
VI.  Prelimimary  Questions  regarding  the  Removal  of 

Cataract  by  Operation,           -            .            .  494 
VII.  Position  of  the  Patient  during  Operations  for 

Cataract,  and  Modes  of  fixing  the  Eye,          .  496 

VIII.  General  Account  of  the  Operations  for  Cataract,  498 

IX.  Depression  and  Reclination,     .            .            .  501 
J .  Depression  and  Reclination  through  the 

Cornea,                 ....  502 
2.  Depression  and  Reclination  through  the 

Sclerotica,             ....  ih. 

X.  Extraction,         .....  511 

1.  Extraction  through  a  semicircular  incision  of 

the  Cornea,           .            .            .            .  511 

2.  Extraction  through  a  Section  of  one-third  of 

the  circumference  of  the  Cornea,              .  524 

3^  Extraction  through  the  Sclerotica,               .  527 

XI.  Division,            .            .            ._           .            .  528 

1.  Division  through  the  Sclerotica,       .            .  ib. 

2.  Division  through  the  Cornea,          .            .  534 
XII.  Choice  of  an  Operation  for  Cataract    Indications 

and  Contra-indications  for  the  difierent  Modes 

of  Operating,               ....  539 

XIII.  Secondary  Cataract,      .            .            .            .  544 

XIV.  Cataract-Glasses,           ....  546 

Chapter  XV.    Artificial  Pupil,           ....  548 

Section      I.  Introductory  View  of  the  Methods  of  forming  an 

Artificial  Pupil,               ....  ib. 
11.  Diseased  States  of  the  Eye  requiring  the  Formation 

of  an  Artificial  Pupil,      .            .            .            .  551 

1.  Partial  Opacity  of  the  Cornea,        .            .  ib. 
%  Partial  Opacity  of  the  Cornea,  with  partial 

Adhesion  of  the  Iris  to  the  Cornea,                .  552 

3.  Closure  of  the  Pupil,  the  Lens  and  Capsule 

being  transparent,            .            .            .  553 

4.  Closure  of  the  Pupil,  loith  Adhesion  of  the 

Iris  to  the  Crystalline  Capsule,    .            .  ib. 

5.  Closure  of  the  Pupil  after  an  Operation  for 

Cataract,              ....  554 

6.  Closure  of  the  Pupil  from  Protrusion  of  Iris 

after  Extraction,               .            .            .  ib. 

7.  Partial  Opacity  of  the  Cornea,  Closure  of  the 

Pupil,  Adhesion  of  the  Iris  to  the  Coimea,  or 

to  the  Capsule,  and  Opacity  of  the  Capsule,  ib. 


XI 


Section        III.  General  Rules  regarding  Artificial  PupU,        .  555 
IV.  Incision,  Excision,  and  Separation  compared ; 

Conditions  necessary  for  these  Operations,  557 

V.  Incision,             .....  561 

1.  Incision  through  the  Sclerotica,        .            .  562 

2.  Incision  through  the  Cornea,           .            .  563 
^  VI.  Excision,            .....  566 

1 .  Lateral  Excision,    ....  ib, 

2.  Central  Excision    .            ,            .            .  568 
VII.  Separation,        .            .            ,            ,            .  ih. 

1.  Separation  through  the  Sclerotica,               ,  ib. 

2.  Separation  through  the  Cornea,       .            .  ib, 
VIII.  Compound  Operations  for  the  Formation  of  an 

*                               Artificial  Pupil,         ....  572 
IX.  Accidents  occasionally  attending  the  Formation 

of  an  Artificial  Pupil ;  After-Treatment,      .  573 


C  HAPTEB  XVI. 


Preternatural  States  of  the  Ibis  independent 

OF  Inflammation,  .  ,  .  575 


Section  I.  Myosis,  .  . 

11.  Mydriasis,  .... 

III.  Tremulous  Iris,  .  , 

Chapter  XVII.    Glaucoma  and  Cats-eye, 

Section  I.  Glaucoma,  .... 

II.  Cats-eye,  .  .  ,  , 

Chapter  XVIII.    Various  States  op  Defective  Vision, 

Section  I.  Myopia,  or  Near-Sightedness, 

II.  Presbyopia,  or  Far-Sightedness, 

III.  Insensibility  to  certain  Colours, 

IV.  Chrupsia,  or  Coloured  Vision, 
V.  Photopsia, 

VI.  Ocular  Spectra,  or  Accidental  Colours. 
VIL  MuscBB  Volitantes, 
VIII.  Spectral  Illusions, 

IX.  Night-Blindness, 
X.  Day-Blindness, 

XL  Hemiopia, 
XII.  Amblyopia,  or  Weakness  of  Sight, 

Chapter  XIX.    Amaurosis, 

Section  I.  General  Account  of  Amaurosis, 

1.  Definition, 

2.  Seat, 

3.  Causes, 

4.  Symptoms, 

5.  Stages  and  Degrees,  , 

6.  Diagnosis, 

7.  Prognosis, 

8.  Treatment, 
II.  Classifications  of  the  Amauroses, 

III.  Illustrations  of  some  of  the  Species  of  Amaurosis, 
1.  Amaurosis  from  Fractured  Cranium  with 
Depression,  or  from  Sanguineous  Extrava- 
sation in  consequence  of  Injury,   . 


ib, 
576 
579 

580 

ib, 
591 

593 

16. 
604 
609 
612 
614 
616 
621 
624 
627 
631 
632 
637 

637 

ib. 

ib. 
638 
641 
643 
649 

ib, 
650 

ib. 
655 
658 


ifi. 


Species  1.  FloccvleTit  Fibrinous  Cataract,  4*6 

Species  2.  Clotted  Fibrinous  Cataract,             .  487 

Species  3.     Trabecular  Fibrinous  Cataract,  th. 

Genus        II.  Purulent  Cataract,   .            .  if>' 

Genus       III.  Sanguinous  Cataract,           .  ib. 

Genus       IV.  Pigmentous  Cataract,           .  488 

III.  Various  additional  Classifications  and  Distinctions 

of  Cataract,              ....  ib- 

1.  Consistence,          ....  ib. 

2.  Size, 489 

3.  Colour,                 ....  lb. 

4.  Duration  and  Development,          .             .  ib. 

5.  Curability,           ....  490 

IV.  Complications  of  Cataract,          ...  ib. 
V.  Treatment  of  Cataract  without  Operation,         .  492 

VI.  Prelimimary  Questions  regarding  the  Removal  of 

Cataract  by  Operation,            -            .            .  494 
VII.  Position  of  the  Patient  during  Operations  for 

Cataract,  and  Modes  of  fixing  the  Eye,          .  496 

Vlll.  General  Account  of  the  Operations  for  Cataract,  498 

IX.  Depression  and  Reclination,     .            .            .  501 
J.  Depression  and  Reclination  through  the 

Cornea,                 ....  502 
2.  Depression  and  Reclination  through  the 

Sclerotica,             ....  ib. 

X'  Extraction,         .            .            .            .            .  511 

1.  Extraction  through  a  semicircular  incision  of 

the  Cornea,           ....  511 

2.  Extraction  through  a  Section  of  one-third  of 

the  circumference  of  the  Cornea,              .  524 

3.  Extraction  through  the  Sclerotica,               .  527 
XL  Division,            .            .            ._           .            .  528 

1.  Division  through  the  Sclerotica,       .             .  ib. 

2.  Division  through  the  Cornea,           .             .  534 
Xn.  Choice  of  an  Operation  for  Cataract     Indications 

and  Contra-indications  for  the  different  Modes 

of  Operating,                ....  539 

Xin.  Secondary  Cataract,      ....  544 

XIV.  Cataract-Glasses,            ....  546 


Chapter  XV.     Artificial  Pupil, 


548 
ib. 


Section      I.  Introductory  View  of  the  Methods  of  forming  an 
xA.rtificial  Pupil, 
II.  Diseased  States  of  the  Eye  requiring  the  Formation 

of  an  Artificial  Pupil,      ....  551 

1.  Partial  Opacity  of  the  Cornea^        .  .  ib. 

2^  Partial  Opacity  of  the  Cornea,  with  partial 

Adhesion  of  the  fris  to  the  Cornea,  .  552 

3.  Closure  of  the  Pupil,  the  Lens  and  Capsule 

being  transparent,  .  .  .  55.3 

4.  Closure  of  the  Pupil,  with  Adhesion  of  the 

Iris  to  the  Crystalline  Capsule,     .  .  ib, 

5-  Closure  of  the  Pupil  after  an  Operation  for 

Cataract,  ....  554 

6.  Closure  of  the  Pupil  from  Protrusion  of  Iris 

after  Extraction,  ...  ib, 

7.  Partial  Opacity  of  the  Cornea,  Closure  of  the 

Pupil,  Adhesion  of  the  Iris  to  the  Cornea,  or 

to  the  Capsule,  and  Opacity  of  the  Capsule,  ib. 


XI 


Section         III.  General  Rules  regarding  Artificial  Pupil,         .  555 
IV.  Incision,  Excision,  and  Separation  compared ; 

Conditions  necessary  for  these  Operations,  557 

V.  Incision,             .....  561 

1.  Incision  through  the  Sclerotica,        .            .  562 

2.  Incision  through  the  Cornea,           .            .  563 

VI.  Excision,             .....  566 

1 .  Lateral  Excision,    .            .            .            ,  iff. 

2.  Central  Excision    ....  568 

VII.  Separation,        .            .            ,            ,            ,  iff, 

1.  Separation  through  the  Sclerotica,               ,  ib. 

2.  Separation  through  the  Cornea,       .            ,  iff, 
VIII.  Compound  Operations  for  the  Formation  of  an 

Artificial  Pupil,         .            ,            .            .  572 
IX.  Accidents  occasionally  attending  the  Formation 

of  an  Artificial  Pupil;  After-Treatment,      .  573 


2  HAPTER  XVI. 


Preternatural  States  of  the  Iris  independent 

OF  Inflammation,  .  ,  .  575 


Section  I.  Myosis,  .  ,  .  . 

II.  Mydriasis,  .... 

III.  Tremulous  Iris,  .  , 

Chapter  XVII.    Glaucoma  and  Cats-eye, 

Section  I.  Glaucoma,  .  .  ,  . 

II.  Cats-eye,  .  ,  ,  , 

CJhapter  XVIII.    Various  States  of  Defective  Vision, 

Section  I.  Myopia,  or  Near-Sightedness, 

II.  Presbyopia,  or  Far-Sightedness, 
ni.  Insensibility  to  certain  Colours, 

IV.  Chrupsia,  or  Coloured  Vision, 
V.  Photopsia, 

VI.  Ocular  Spectra,  or  Accidental  Colours, 
VII.  MuscsB  Volitantes, 
VIII.  Spectral  Illusions, 

IX.  Night-Blindness, 

X.  Day-Blindness, 

XI.  Hemiopia, 
XII.  Amblyopia,  or  Weakness  of  Sight, 

IIJhapter  XIX.    Amaurosis, 

Section  I.  General  Account  of  Amaurosis, 

1.  Definition, 

2.  Seat, 

3.  Causes, 

4.  Symptoms, 

5.  Stages  and  Degrees,  , 

6.  Diagnosis,  »  * 

7.  Prognosis, 

8.  Treatment, 
II.  Classifications  of  the  Amauroses, 

III.  Illustrations  of  some  of  the  Species  of  Amaurosis, 
1.  Amaurosis  from  Fractured  Cranium  unth 
Depression,  or  from  Sanguineous  Extrava- 
sation in  consequence  of  Injury,   . 


ib. 
576 
579 

580 

ih, 
591 

593 

ib, 
604 
609 
612 
614 
616 
621 
624 
627 
631 
632 
637 

637 

ib. 

ib. 
638 
641 
643 
649 

ib. 
650 

ib. 
655 
658 


i6. 


xn 

2.  Amaurosis  from  Cerebral  Plethora  and  Conges' 

tion,         .....  660 

3.  Amaurosis  frovi  Apoplexy,  .  .  664 

4.  Amaurosis  from  Aneurismal  Dilatation  of  the 

Cerebral  Aiieries,  .  .  •  ib» 

5.  Amaurosis  from  Ir^ammation,  brought  on  by 

Exposure  of  the  Eyes  to  Intense  lAght,  or 
by  Over-action  of  the  Sight, 

6.  Amaurosis  from  Concussion,  or  other  Injury  of 

the  Head,  .... 

7.  Amaurosis  from  Inflammation  of  the  Brain, 

consequent  to  Scarlatina, 

8.  Amaurosis  from  Inflammation  of  the  Brain 

,  consequent  to  Suppression  of  the  Menses, 

9.  Amaurosis  from  Inflammation  of  the  Brain, 

consequent  to  Suppressed  Purulent  Dis- 
charge, .... 

10.  Amaurosis  from  Inflammation  of  the  Brain, 

consequent  to  Suppressed  Perspiration,    . 

11.  Amaurosis  from  Morbid  Changes  in  the 

Optic  JVerve,        .... 

12.  Amaurosis  from  Morbid  Formations  in  the 

Brain,      ..... 

13.  Amaurosis  from  Morbid  Changes  in  the  Mem- 

branes, or  in  the  Bones  of  the  Cranium,   . 

14.  Amaurosis  from  Morbid  Changes  affecting  the 

Fifth  Pair  ofJVerves, 

15.  Amaurosis  from  Poisons,    . 

16.  Amaurosis  from  Inanition  or  Debility, 

17.  Amaurosis  from  Irritation  of  the  Branches  of 

the  Fifth  Pair  of  JVerves, 

18.  Amaurosis  from  Worms  in  the  Intestines,    . 
15L  Amaurosis  from  Acute  or  Chronic  Disorders 

of  the  Digestive  Organs, 


PRACTICAL  TREATISE 


DISEASES    OF    THE    EYE 


CHAPTER    I. 

DISEASES  OF  THE  ORBIT. 


Supposing  my  reader  to  be  acquainted  with  the  structure  and  con- 
tents of  the  orbit,  and  with  its  relations  to  the  surrounding  cavilies 
of  the  nostril,  the  frontal,  maxillary,  and  sphenoid  sinuses,  and  the 
cranium,  I  purpose  in  the  following  chapter  to  review  the  chief  dis- 
eases to  which  the  orbit  is  liable. 

SECTION  I. INJURIES  OF  THE  ORBIT. 

I  Under  the  head  of  Injuries,  I  may  mention,  first  of  all.  Contu- 
sion producing  inflammation  and  caries  of  the  bones  forming  the 
edge  of  this  cavity,  Fractures,  and  Penetrating  Wounds  of  the  Or- 
bit. Incised  wounds,  laying  open  the  orbit,  must  from  their  nature 
be  rare  ;  yet  some  interesting  cases,  even  of  this  sort,  are  recorded. 
Many  Gunshot  wounds  of  the  orbit  are  related.  Indeed,  numerous 
examples  of  the  perforation  of  every  part  of  the  face  and  head  Ijy 
balls,  must  present  themselves  after  a  battle  to  the  notice  of  mihta- 
ry  surgeons. 

It  is  not  my  intention  at  present  to  treat  of  injuries  of  the  parts 
contained  within  the  orbit.  Yet  it  is  impossible  altogether  to  avoid 
noticing  the  effects  produced  on  the  contents  of  this  cavity,  while 
considering  injuries  of  the  orbit  itself ;  or,  while  treating  of  wounds 
penetrating  the  walls  of  the  orbit,  to  pass  over  in  silence  the  inju- 
ries which  in  this  way,  the  brain  and  other  surrounding  organs  may 
sustain.  Cases  occur,  indeed,  in  which  it  is  doubtful,  to  the  injury  of 
what  particular  part,  without,  within,  or  beyond  the  orbit,  the  con- 
sequences of  an  injury  ought  to  be  attributed.  Amaurosis,  for  ex- 
ample, one  of  the  chief  consequences  to  be  apprehended  from  wounds 
of  the  orbit,  is  sometimes  owing  to  injury  of  the  branches  of  the 
I 


fifth  pair  of  nerves  without  the  orbit :  in  other  cases,  to  injury  ol 
the  optic  or  other  nerves  within  the  orbit,  or  of  the  e3'e  itself;  and 
in  other  cases,  to  injury  of  the  brain. 

i.  Contusions  and  Cuts  upon  the  Edge  of  the  Orbit 

May  happen  from  a  blow  with  the  fist,  with  a  stone,  with  a 
stick ;  from  a  fall  on  the  sharp  corner  of  a  table,  from  a  feill  on  the! 
street;  and  from  many  similar  accidents.  It  is  only  in  scrofulous | 
children,  and  in  the  malar  bone  that  I  have  seen  the  inflammation, 
arising  from  such  accidents,  run  on  into  suppuration,  and  affect  the 
periosteum  and  even  the  substance  of  the  bone.  But  of  course,  the 
two  other  bones,  which  assist  in  forming  the  external  aperture  of 
the  orbit,  and  especially  the  frontal,  may  be  similarly  injured,  and  I 
give  rise  to  a  long-continued  ailment.  ! 

After  the  abscess  in  such  a  case  is  opened,  thin  serous  pus  con-| 
tinues  to  be  discharged  for  many  weeks  ;  but  at  length,  if  the  tex-| 
ture  of  the  bone  is  not  afiected,  the  matter  diminishes  in  quantity, ! 
grows  thick,  and  ceases  entirely.  If,  on  the  other  hand,  caries  has , 
begun,  the  discharge  continues  ;  it  sometimes  becomes  curdy  ;  the  | 
opening  turns  fistulous  ;  the  skin  around  the  opening  is  dragged  to- . 
wards  the  bone  ;  the  edges  of  the  opening  throw  out  fungous  gran- 
ulations ;  and  the  eyelid,  partaking  in  the  dragging  of  the  skin,  is 
more  or  less  everted. 

This  is  a  state  of  matters  which  we  have  ver}^  little  power  of 
checking.  Being  a  caries  from  an  external  cause,  it  may  be  re- 
garded, indeed,  as  less  dangerous  than  one  arising  from  constitu- 
tional disease  :  yet  it  must  be  more  by  improving  the  general  health 
than  by  local  means,  that  the  bone  is  to  be  restored  to  a  sound 
state.  The  youth  of  the  subject  leads  to  a  favourable  prognosis  ;  ' 
the  scrofulous  diathesis  is  unfavourable. 

In  the  inflammatory  stage,  before  there  is  any  suspicion  of  mat- 
ter being  about  to  form,  leeches  ought  to  be  liberally  applied  over 
the  bruise.  I  am  the  more  disposed  to  advise  this,  in  all  cases  of 
bruise  over  the  edge  of  the  orbit,  from  having  met  with  cases  of 
this  kind,  vrhich  having  been  thought  too  lightly  of,  and  therefore 
not  treated  with  leeches,  ran  the  course  which  I  have  described  ; 
but  which,  it  is  probable,  might  have  been  prevented  from  doing  so. 
had  proper  antiphlogistic  means  been  employed. 

If  an  abscess  forms,  it  is  to  be  opened  as  far  from  the  edge  of  the 
eyelid  as  can  be  conveniently  done,  in  order  to  avoid  as  much  as 
possible   the  eversion  which  is  apt  to  follow. 

If  the  probe,  introduced  to  the  bottom  of  the  opening,  comes  in- 
to contact  with  diseased  bone,  an  injection  of  a  strong  solution  of 
lunar  caustic  may  be  imployed,  or  the  pencil  of  lunar  caustic  may 
be  filed  down  to  the  proper  degree  of  slenderness,  and  introduced 
along  the  opening,  till  it  touches  the  diseased  bone.  The  applica- 
tions may  be  continued  from  time  to  time,  till  the  disease  of  the 
bone  is  overcome. 


Change  of  air,  nourishing  diet,  attention  to  the  bowels,  and  the 
jse  of  tonics,  are  also  to  be  recommended.  The  long-continued 
}mplo3anent  of  the  decoction  of  sacsaparilla  is  likely  to  be  benefit 
^ial. 

After  such  a  case  has  recovered,  the  integuments  are  generally 
:bund  to  remain  immovably  attached  to  the  periosteum,  where  the 
istulous  opening  existed. 

From  blows  on  the  edge  of  the  orbit,  particularly  its  upper  edge, 
ive  must  be  prepared  to  meet  with  much  more  serious  consequen- 
ces, than  merety  an  affection  of  the  bone  or  its  periosteum.  EfTu- 
ion  of  blood  within  the  cranium,  and  inflammation  of  the  brain  or 
ts  membranes  maybe  excited  by  such  an  injury  ;  and  while  our 
ears  are  perhaps  confined  to  the  state  of  the  bone,  or  of  the  soft  parts 
kvhich  invest  it,  changes  may  be  proceeding  within,  which  shall 
juddenl}'^  prove  fatal.* 

i  Consequences  not  less  serious  have  been  known  to  result  from 
[injuries  of  a  similar  sort,  received  at  the  lower  edge  of  the  orbit. 
Thus  Petit  relates  a  case  of  palsy  of  the  left  side,  and  death,  from 
suppuration  in  the  right  hemisphere  of  the  brain,  consequent  to  a 
wound  at  the  lower  edge  of  the  right  orbit,  close  to  the  exit  of  the 
infra-orbitary  nerve,  which,  however,  did  not  appear  to  have  been 
injured. t 

Contusion  of  the  temporal  edge  of  the  orbit  has  been  sometimes 
followed  by  the  growth  of  encysted  and  other  tumours  within  the 
Drbit.  These,  however,  as  well  as  inflammations  of  the  vaiious 
parts  contained  within  the  orbit,  and  the  formation  of  exostosis, 
excited  by  the  same  cause,  will  require  separate  consideration  here- 
after. 

2.  Fractures  of  tJie  Edge  of  the  Orbit, 

The  only  instance  which  I  recollect  to  have  seen  of  this  injury, 
was  from  a  blow  with  the  end  of  a  long  piece  of  wood,  which 
struck  the  lower  edge  of  the  orbit,  and  separated  a  fragment,  which 
I  concluded  to  be  the  anterior  angle  of  the  malar  bone.  The  frac- 
tured piece  moved  at  first  easily  under  the  finger,  in  different  direc- 
tions, but  became  united  in  the  course  of  a  few  weeks.  No  bandage 
was  apphed  ;  but  cases  may  occur,  in  which,  the  eyelids  being 
previously  closed,  a  small  linen  compress,  and  a  roller  round  the 
head,  might  be  judiciously  employee},  to  press  a  fractured  piece  of 
the  edge  of  the  orbit  into  contact  with  the  bone  from  which  it  had 
been  separated,  till  the  process  of  reunion  be  completed. 

Fracture  of  the  upper  edge  of  the  orbit  is  apt  to  penetrate  into 
the  frontal  sinus  ;  and  the  consequence  sometimes  is,  that  on  blow- 
ing the  nose,  air,  passing  from  the  sinus,  and  through  the  fracture, 

*  CEuvres  d'Ambrose  Pare ;  Liv.  s.  Chap.  9.  Dease's  Observations  on  Wounds 
of  the  Head,  p.  107.     London,  1776. 

t  Nouveau  Systeme  du  Cerveau,  par  F.  P.  du  Petit,  contained  in  the  CEuvres  di- 
verses  de  Louis,  Tome  ii.  p.  41.  Paris,  1788. 


is  introduced  into  the  cellular  membrane  of  the  eyelids.  In  such  a 
case,  the  integuments  may  be  opened  with  the  lancet,  to  let  the  air 
escape. 

3.  Fractures  of  the  Walls  of  the  Orbit,  attending  Frac- 
turtd  Skull. 

Fractures  of  the  skull  not  unfrequently  extend  to  one  or  both  of 
the  orbits  ;  and  it  is  worthy  of  particular  observation,  that  fracture 
of  the  roof  of  the  orbit  in  this  way,  is  apt  to  be  attended  by  lacera- 
tion of  the  dura  mater,  and  injury  of  the  anterior  lobes  of  the  cere- 
brum, which  rests  upon  the  orbits.  Now,  suppose  that  this  is  the 
case,  while  at  the  same  time  a  fracture  with  depression  is  present, 
we  shall  say  on  the  temple,  and  that  this  fractured  piece  of  skull  is 
raised  into  its  place  in  the  operation  of  trepan,  the  patient  will,  in 
all  probability,  not  be  relieved  by  this  operation,  the  symptoms  of 
pressure  on  the  brain,  or  of  inflammation  within  the  skull,  will 
most  likely  remain  as  before,  and  death  follow,  contrary,  perhaps, 
to  what  might  have  been  expected,  if  the  fractured  temple  had 
been  the  sole  iniur3^  It  will  probably  be  only  on  dissection,  that 
in  such  a  case  the  cause  of  death  will  he  discovered. 

Dr.  Ballingall  has  recorded  a  case  of  compound  fracture  of  the 
OS  frontis,  in  which,  after  the  depressed  pieces  of  bone  were  re- 
moved, the  patient  instantly  recovered  his  senses,  and  answered 
questions  rationally.  He  soon  lapsed,  however,  into  a  comatose 
state,  and  died  within  48  hours  of  the  receipt  of  the  injury.  On 
dissection,  the  fracture  was  found  to  extend  backwards,  through 
both  orbitary  plates  of  the  frontal  bone,  and  to  pass  across  the 
ethmoid  behind  the  crista  galli.  Opposite  to  the  fissures  in  the 
roof  of  each  orbit,  the  dura  mater  was  found  lacerated  to  a  con- 
siderable extent,  and  portions  of  brain  protruding.  The  anterior 
lobes  of  the  brain  were  disorganized  and  broken  down  ;  and,  what 
was  remarkable,  a  distinct  appearance  of  purulent  matter  was  seen 
upon  the  tunica  arachnoidea  covering  each  hemisphere  of  the  brain, 
although  the  patient  had  survived  the  accident  for  so  short  a  time, 
lost  a  considerable  quantity  of  blood  from  the  wound,  and  manifes- 
ted no  inflammatory  symptoms.* 

In  cases  of  fractured  skull  extending  to  the  orbit,  it  sometimes 
happens,  that  portions  of  the  walls  of  that  cavity  are  so  completely 
separated,  that  they  easily  come  away,  either  in  dressing  the 
wound,  or  in  raising  and  removing  the  depressed  pieces  of  the  skull. 
The  mere  circumstance  of  a  portion  of  bone  being  loose,  is  not 
sufficient  ground  for  removing  it ;  its  surfaces  being  still  attached 
to  the  membranes  with  which  they  are  naturally  in  connexion,  it 
may  be  susceptible  of  reunion ;  but  if  the  bone  be  extremely 
shattered,  and  pressed  partly  through  the  dura  mater,  we  may  be 


*  Clinical  Lecture  in  the  Royal  Infirmary  of  Edinburgh,  March  1828,  by  George 
Ballingall,  M.  D.,  p.  5. 


J'  warranted  in  removing  the  loose  pieces.  Cheselden  has  communi- 
I  cated  a  remarkable  case  of  this  kind,  which  occurred  in  the  practice 
of  Mr.  Cagua,  a  surgeon  of  Plymouth,  in  which  five  splinters  of  the 
cranium,  which  were  depressed  into  the  substance  of  the  brain, 
were  extracted,  the  largest  piece  comprehending  part  of  the  orbitary 
plate  of  the  frontal,  of  the  great  wing,  of  the  sphenoid,  and  of  the 
i  suture  which  connects  the  external  angular  process  of  the  frontal  to 
the  superior  angle  of  the  malar  bone.  Pieces  of  the  substance  of 
the  brain  followed  the  removal  of  this  splinter ;  yet  the  patient,  a 
boy  of  10  years  of  age,  perfectly  recovered.* 

4.  Counter-Fractures  of  the  Orhit. 

Fractures  of  the  orbit  sometimes  take  place,  we  are  told,  by  what 
the  French  have  called  contrecoup,  in  consequence  of  falls  on  the 
forehead,  or  even  on  the  occiput.  It  is  seldom,  if  ever,  that  such 
fractures  are  discovered  till  after  death.  Indeed,  it  is  of  compara- 
tively little  importance  to  know  of  their  existence  during  life,  as 
they  do  not  admit  of  any  particular  treatment,  and  as  our  attention 
must  be  almost  entirely  directed  to  the  concussion,  and  consequent 
inflammation  of  the  brain,  by  which  counter-fractures  are  invariably, 
or  almost  invariably,  attended. 

5.  Penetrating  Wounds  of  the  Walls  of  the  Orhit. 
The  smallness  of  the  eyeball,  compared  with  the  size  of  the  cavi- 
ty in  which  it  is  placed,  and  its  firm  resistance,  compared  with  the 
looseness  of  the  parts  interposed  between  it  and  the  orbit,  explain 
at  once  how  pointed  bodies,  thrust  against  the  eye,  are  very  apt  to 
leave  the  eyeball  uninjured,  and  to  penetrate  deep  into  the  cavity 
of  the  orbit,  or  even  passing  through  its  walls,  to  enter  one  or  other 
of  the  neighbouring  cavities.  The  sides  of  the  orbit  which  are 
turned  towards  the  nostril  and  cranium,  from  their  situation  and 
extreme  thinness,  are  especially  exposed  to  be  thus  injured.  Per- 
foration of  the  orbitary  plate  of  the  frontal  bone,  in  particular,  is  an 
accident  to  which  the  attention  of  the  surgical  student  is  early  and 
forcibly  drawn.  The  thinness  and  fragihty  of  that  plate,  the  readi- 
ness with  which  the  brain  may  be  reached  through  it,  and  the  in- 
stantaneousness  with  which  death  has  been  known  to  follow 
such  an  injury,  make  an  indelible  impression  on  the  mind  of  the 
young  anatomist.  Thus  Mr.  John  Bell,  after  attributing  the  thin- 
ness of  the  orbitary  plate  to  "  the  continual  rolling  of  the  eye,"  with 
which  that  plate  never  comes  into  contact,  and  by  which,  therefore, 
it  cannot  be  thinned,  tells  us,  that  "  it  is  the  aim  of  the  fencer ; 
and  w-e  have  known  in  this  country,"  adds  he,  "a  young  man 
killed  by  the  push  of  a  foil,  which  had  lost  its  guard.t 

*  Philosophical  Transactions  for  1740.  Vol.  xli.  Part  II.  p.  495. 

+  Bell's  Anatomy.  Vol.  i.  p.  49.  London,  1811.  The  thinness  of  the  orbitary 
plate,  like  the  thinness  of  the  middle  of  the  os  illium,  or  the  middle  of  the  scapula, 
must  be  regarded  as  the  natural  constitution  of  the  bone,  and  not  at  all  as  the  effect 
of  pressure  of  the  brain,  or  rolling  of  the  eye. 


6 

Various  effects  may  follow  a  penetrating  wound  of  the  orbit,  and 
we  may  find  the  patient  in  one  or  other  of  very  different  states  ;  for 
the  weapon  may  have  been  immediately  withdrawn  after  the  injury 
was  inflicted,  or  the  foreign  body  may  still  be  fixed  in  the  wound, ; 
and  is  to  be  extracted,  or  it  may  have  sunk  so  deep,  that  it  cannot 
be  laid  hold  of:  and  as  for  the  effects  of  the  injury,  they  may  be 
slight  and  transient,  or  violent  and  immediately  dangerous,  or 
prolonged  for  a  length  of  time.  It  is  evident,  that  a  dagger,  or 
other  weapon,  directed  outwards,  so  as  to  break  through  the  suture 
between  the  malar  and  sphenoid  bones  into  the  temporal  fossa,  or 
directed  downwards,  so  as  to  shatter  the  floor  of  the  orbit,  and  enter 
the  maxillary  sinus,  will  not  be  productive  of  the  same  amount  of 
dangerous  consequences,  as  when  the  instrument  of  injury  traverses 
the  03  planum  of  the  ethmoid,  or  the  orbitary  plate  of  the  frontal. 
I  shall  speak  of  gunshot  wounds  of  the  orbit  separately  ;  but  I  may 
here  remark,  that  their  effects  correspond  so  far  at  least  with  those 
of  common  penetrating  wounds,  that  from  both  we  may  occasion- 
ally expect  haemorrhage,  extravasation  of  blood,  blindness,  strabis- 
mus, syncope,  vomiting,  coma,  convulsions,  palsy,  death,  as  im- 
mediate effects ;  and  as  remote  effects,  fever,  delirium,  suppura- 
tion, caries,  exfoliation  of  bone,  and  the  like. 

1 .  Trijling  ajypearance  of  external  v)oimd.  A  weapon  pene- 
trating through  the  orbit,  may  strike  deep  into  the  brain,  and  yet 
so  small  an  external  wound  be  present,  as  shall  be  apt  to  excite  lit- 
tle or  no  suspicion  of  danger. 

Ruysch  relates  the  case  of  a  man,  who  was  wounded  in  the  left 
orbit,  with  the  end  of  a  stick,  not  particularly  sharp.  The  injury 
appeared  of  httle  importance  ;  yet  the  patient  died  soon  after  re- 
ceiving the  wound.  The  magistrates  appointed  Ruysch  to  exam- 
ine the  body,  in  order  to  discover  the  cause  of  the  sudden  death. 
Externally,  he  observed  a  slight  degree  of  ecchymosis  at  the  upper 
part  of  the  eye  ;  but  on  removing  the  calvarium,  he  found  that  the 
wound  had  penetrated  to  a  considerable  depth  into  the  brain.  This, 
he  observes,  may  happen  very  easily,  on  account  of  the  thinness  of 
the  upper  part  of  the  orbit,  in  many  not  thicker  than  writing  paper, 
and  so  brittle  as  to  be  perforated  with  the  finger.  Wounds,  there- 
fore, of  the  orbit,  he  concludes,  are  not  to  be  considered  as  a  matter 
of  no  moment,  especially  if  the  instrument  by  which  they  are  in- 
flicted is  not  blunt,  or  if  those  who  are  wounded  become  sleepy, 
sick,  feverish,  giddy,  or  convulsed.* 

Peter  Borel  mentions  a  still  more  remarkable  case,  of  a  man  who 
was  wounded  with  a  sword  in  the  left  orbit.  Thinking  that  the 
wound  had  not  penetrated  deep,  he  merely  covered  it  with  a  plas- 
ter ;  after  which  he  walked  two  leagues,  and  ate  and  drank  heartilj- 
with  his  companions,  exactly  as  if  he  had  been  well,  being  affected 
with  no  pain.     Next  morning  he  was  found  dead.     The  skull  was 

*  Ruyschii  ObservationumCenturia.     Obs.  54.     Amstelodami,  1691. 


opened,  when  the  wound  was  found  to  have  penetrated  to  the  cere- 
bellum.* 

These  two  cases  are  sufficient  to  show  how  cautiously  our  prog- 
nosis ought  to  be  delivered,  when  a  wound  appears  to  have  pene- 
trated to  any  depth  towards  the  roof  of  the  orbit. 

2.  Situation  and  extent  of  fractured  orbit  different  in  differ- 
ent cases.  It  is  worthy  of  remark,  that  it  is  not  the  obitary  plate 
of  the  frontal  bone  alone  which  is  apt  to  be  fractured  when  the 
weapon  is  directed  towards  the  roof  of  the  orbit ;  and  that  we  are 
sometimes  enabled  to  judge  of  the  degree  of  violence  employed  by 
the  hand  which  held  the  weapon,  even  by  the  mere  situation  of 
the  fracture,  which  in  fatal  cases  is  detected  on  dissection. 

The  following  case  of  fatal  wound  of  the  brain  though  the  eth- 
moid bone,  is  quoted  by  Bonetus.  A  countryman,  about  55  years 
of  age,  was  asked  by  one  who  met  him  to  step  out  of  the  way ;  but 
as  he  was  carrying  a  heavy  burden  at  the  time,  he  could  not  do  so, 
and  therefore  refused.  The  other,  provoked  at  this,  struck  the 
countryman  violently  over  the  shoulders  with  a  whip  ;  and  when 
the  whip  broke,  thrust  the  sharp  end  of  the  broken  stick  of  the 
whip  in  the  countryman's  face.  Not  apprehending  any  dangerous 
effects  from  the  blows  which  he  had  received,  the  countryman, 
with  his  burden  on  his  back,  trudged  along  after  his  cart,  which 
was  loaded  with  wood,  for  nearly  a  quarter  of  a  mile,  till  he  arrived 
at  the  wood  market,  when  he  instantly  dropped  down  dead. 
Schmid  was  appointed  to  inspect  the  body.  On  examining  the 
head  externally,  he  found  that  the  sharp  end  of  the  stick  had  pen- 
etrated at  the  internal  canthus  of  the  right  eye.  He  endeavored  to 
ascertain  with  the  probe  whether  the  wound  had  reached  the  brain, 
but  he  could  not,  on  account  of  the  smallness  of  the  wound. 
Having  opened  the  cranium,  the  brain  and  its  membranes  at  first 
view  appeared  sound  ;  but  on  raising  the  anterior  part  of  the  cere- 
brum, the  nasal  extremity  of  the  falx  was  seen  to  be  injured,  and 
it  was  found  that  the  wound  had  penetrated  into  the  third  ventri- 
cle, in  which  la}^  a  considerable  quantity  of  grumous  blood.t 

Some  years  ago,+  I  witnessed  the  examination  of  the  body  of  a 
man,  who,  the  evening  before,  had  almost  instantaneously  dropped 
down  dead,  in  a  scuffle  on  the  street,  after  receiving  a  penetrating 
wound  of  the  orbit,  with  the  pointed  end  of  an  umbrella.  Con- 
siderable bleeding  had  taken  place  from  the  nose  and  mouth.  The 
upper  eyelid  was  swollen  and  livid,  and  the  conjunctiva  elevated 
by  extravasated  blood.  Just  over  the  tendon  of  the  orbicularis 
palpebrarum,  a  penetrating  wound  easily  admitted  the  little  finger 
to  the  bottom  of  the  orbit,  between  its  nasal  side  and  the  eyeball. 

*  Petri  Borelli  Historiarum  et  Observationum  Centuria  II.     Obs.  19.  Francofurti, 
1676. 
t  Joannis  Schmidii  Miscellanea  ;  quoted  by  Bonetus  in  his  Sepulchretum.     Tome 
I    iii.  p.  380.  Lugduni,  1700. 
t  20th  December,  1819- 


8 

The  end  of  the  finger  felt  a  fracture  of  the  orbit.  On  opening  the 
head,  much  dark  fluid  blood  was  found  eflused  into  the  cavity  of 
the  tunica  arachnoidea,  and  some  between  it  and  the  pia  mater. 
The  dura  mater  was  seen  to  be  perforated  by  a  lacerated  wound, 
just  under  the  edge  of  the  boundary  of  the  middle  fossee  of  the  ba- 
sis of  the  cranium,  formed  by  the  little  wing  of  the  sphenoid  bone. 
The  brain  behind  the  wound  of  the  dura  mater  was  lacerated, 
and  a  small  portion  of  it  separated  from  the  rest.  On  removing 
the  dura  mater,  the  fracture,  which  had  been  seen,  indeed,  imme- 
diately on  hfting  the  brain,  was  displayed  to  view.  The  little  wing 
of  the  sphenoid  was  separated  by  the  fracture  from  the  frontal  bone, 
in  the  course  of  the  sphenoidal  suture.  The  fracture  extended 
through  the  orbitary  plate  of  the  frontal  from  behind  forward  for 
about  half  its  length  ;  but  what  was  much  more  remarkable,  the 
comparatively  thick  and  strong  portion  of  the  sphenoid,  which 
completes  the  posterior  part  of  the  roof  of  the  orbit,  was  broken 
across  at  its  inner  extremity  :  proving,  along  with  the  state  of  the 
dura  mater  and  brain,  the  great  degree  of  force  with  v/hich  the 
instrument  of  death  had  been  driven  against  the  hapless  victim  of  a 
drunkard's  fury.  I  may  mention,  that  the  optic  nerve  ^and  eyeball 
were  entire,  the  cornea  lively,  and  the  humors  and  retina  uninjured. 
3.  Convulsions — Suppuration.  Thecasewhichlam  now  about 
to  quote,  serves  at  once  to  confirm  what  is  proven  by  the  preceding 
cases,  namely,  that  at  the  first  there  may  be  nothing  alarming,  ex- 
cept the  suspicious  situation  of  the  wound  ;  exemplifies  a  symptom, 
which  has  ever  been  regarded  as  an  exceedingly  dangerous,  if  not 
fatal,  one  in  injuries  of  the  brain,  name]}',  convulsions  ;  and  illus- 
trates in  accidents  of  this  kind,  both  the  date  and  the  effects  of  sup- 
puration. The  earliness  with  which  matter  is  formed  by  the  tunica 
arachnoidea,  in  cases  of  wounded  brain,  is  a  remarkable  circum- 
stance, and  is  strikingly  proven  by  the  case  already  quoted  from 
Dr.  BallingalPs  Chnical  Lecture. 

A  soldier  was  brought  to  the  hospital  at  Brest,  at  11  o'clock  in 
the  evening,  having  been  wounded  with  a  pitchfork,  at  the  middle 
of  the  left  upper  eyelid.  The  wound  was  obHque,  about  three  hnes 
in  length,  and  appeared  to  have  injured  only  the  skin  and  orbicul- 
aris palpebrarum ;  there  was  very  httle  blood  discharged  ;  the  eye- 
lid was  distended,  and  the  conjunctivea  inflamed.  The  apparent 
simplicity  of  the  wound,  the  goodness  of  the  pulse,  and  the  free  ex- 
ercise of  all  the  functions,  led  to  a  favourable  prognosis ;  the  pa- 
tient asserted  that  he  experienced  nothing  particular  at  the  moment 
of  the  injury ;  scarcely  had  he  been  stupified  by  it.  Compresses, 
dipped  in  brandy  and  water,  were  applied  over  the  wound.  The 
patient  rested  during  the  night ;  next  day,  he  was  quite  lively, 
walked  about  in  the  wards,  complained  only  of  slight  pain  in  the 
region  of  the  wound,  and  even  ate  with  appetite.  The  same  day, 
at  7  in  the  evening,  he  was  seized  with  convulsions,  which  were 
supposed  by  his  attendants  to  be  epileptic.     The  day  after,  he  was 


kept  from  food,  and  bled  at  the  arm  ;  the  convulsions  returned, 
and  he  was  bled  at  the  foot.  Vomiting,  uneasiness,  agitation,  and 
delirium  came  on;  the  pulse  became  small  and  contracted;  cold 
sweats  succeeded,  and  the  patient  died  at  2  o'clock  next  morning. 
On  dissection,  the  eyelids  were  found  oedematous,  but  the  wound 
had  already  closed.  On  cutting  through  the  upper  eyelid  and  or- 
bicularis palpebrarum,  a  circumscribed  collection  of  pus  was  found 
in  the  orljit,  between  its  roof  and  the  levator  palpebree  superioris. 
This  collection  of  pus  communicated  with  the  cranium,  through 
the  orbitary  plate  of  the  frontal  bone,  which  had  been  pierced 
through  and  through  by  one  of  the  prongs  of  the  fork.  After 
removing  the  eyeball,  the  inferior  wall  of  the  orbit  was  found 
fractured,  and  depressed  almost  completely  into  the  maxillary  sinus. 
This  fracture  was  without  fragments,  and  is  compared  by  M.  Mas- 
sot,  the  relator  of  the  case,  to  the  depression  which  might  be  pro- 
produced  on  the  surface  of  an  egg,  by  pressing  it  inwards  with  the 
thumb.  On  removing  the  calvarium,  the  dura  mater  was  seen  to 
be  penetrated  over  the  hole  made  by  the  fork  in  the  roof  of  the 
orbit.  The  dura  mater  appeared  diseased  at  that  place,  the  ante- 
rior fossae  of  the  basis  of  the  cranium  were  covered  with  pus,  the 
anterior  lobes  of  the  cerebrum  were  in  a  state  of  suppuration,  and 
the  rest  of  the  brain  healthy.  M.  Massot  thinks  it  probable,  that 
when  the  fork  was  pushed  through  the  orbit  into  the  cranium,  the 
eyeball  being  fixed  and  violently  pressed  between  the  fork  and  the 
floor  of  the  orbit,  the  thin  plate  of  the  superior  maxillary  bone  could 
not  resist  this  pressure,  but  sunk  by  the  continued  action  of  the 
fork  upon  the  eyeball." 

4.  Palsy.  In  those  who  survive  wounds  penetrating  the  sides 
of  the  orbit,  we  may  expect  occasionally  to  meet  with  paralytic 
affections. 

A  case  of  this  kind  is  recorded  by  Mr.  Geach,  a  surgeon  at  Ply- 
mouth. He  does  not  indeed  say  that  the  wound  penetrated  into 
Lhe  brain,  but  merely  that  the  instrument  of  injury  struck  against 
the  inner  side  of  the  orbit ;  leaving  it  a  matter  of  doubt,  whether 
Lhe  paralytic  symptoms  which  followed  were  attributable  to  effu- 
sion within  the  cranium,  or  to  a  still  more  direct  injury  of  the 
brain. 

A  midshipman  was  wounded  in  a  riot  by  a  small-sword,  which, 
entering  at  the  external  angle  of  the  left  eye.  and  passing  quite 
through  the  eye,  struck  against  the  inner  part  of  the  orbit.  He 
fell  down  instantaneously  senseless,  with  loss  of  speech,  and  hemi- 
plegia of  the  opposite  side.  Blood  was  immediately  drawn.  Next 
morning,  he  was  found  lying  on  his  back,  with  the  right  eye  widely 
opened,  and  the  pupil  (though  in  a  light  room)  considerably  di- 
lated. This  eye  was  incapable  of  discerning  objects,  never  winking 
I  at  the  waving  of  the  hand,  or  the  close  application  of  the  finger, 

i  *  Journal  de  MeJecine,  Tome  iii.  p.  530.  Q,uoted  in  the  Dictionnaire  des  Sciences 
,Medicales;  Tome  xxxvii.  p  558. 

il  2 


10 

though  sometimes  it  was  convulsed.  The  left  eye  was  extruded 
from  its  orbit,  and  though  destitute  of  all  its  humors,  was  enlarged  to 
the  size  of  a  pullet's  egg.  The  pulse  beat  at  long  intervals,  with  a 
lazy  motion,  and  stopped  upon  gentle  pressure  ;  the  body  was  not 
feverish,  but  preserved  a  natural  heat,  the  paralytic  side,  arm,  and 
thigh  excepted,  which  were  livid,  cold  and  rigid ;  the  lancet  was 
employed  without  exciting  any  sensation,  and  blisters  lay  on  sev- 
eral days  without  raising  any  vesications ;  the  benumbed  parts 
were  constant^  bedewed  with  clammy  sweat.  The  patient  was 
devoid  of  anxiety,  or  inquietude,  and  the  powers  of  life  seemed  to  be 
almost  suspended ;  purgatives  produced  no  effect,  and  clysters, 
though  repeatedly  injected,  were  never  repelled.  The  urine  was 
in  general  emitted  by  drops  only,  but  sometimes  it  would  run  off 
suddenly  in  a  deluge;  hearing  was  considerably  impaired;  the 
patient  lay  lethargic,  and  dead  almost  to  every  thing,  though  by 
pulling  the  arms  and  shaking  the  body,  by  loud  and  frequent  cal- 
ling, and  desiring  him  to  extend  his  tongue,  he  would  gape  widely, 
and  forgetting  seemingly  what  had  been  said  to  him,  keep  his 
mouth  wide  open,  when  the  tongue  might  be  seen  quivering  and 
retracted.  Five  weeks  elapsed  in  this  state  of  insensibility  ;  every 
thing  he  took  was  with  voracity,  but  without  relish  or  distinction. 
About  this  time  a  new  symptom  began  to  threaten  ;  the  jaw 
seemed  to  be  moved  with  difficulty,  and  liquids  only  could  be 
poured  down  ;  the  hypochondria  were  hard  and  distended,  and 
every  effort  to  procure  an  intestinal  discharge  ineffectual ;  when 
very  large  eruptions  of  the  miliary  kind  were  suddenly  diffused 
over  the  sound  parts.  From  that  critical  moment  he  perspired 
freely,  and  had  an  easy  motion  of  the  jaw ;  his  urine  was  rendered 
in  due  quantity,  and  purgatives  of  the  lenient  kind  easily  operated  ; 
the  hypochondria  became  soft ;  the  discharge  from  the  eye,  which 
had  hitherto  been  acrid,  was  now  copious  and  laudable ;  the  sound 
eye  had  its  motion,  he  could  see  distinctly,  and  seemed  in  other 
respects  sensible,  when  roused  from  his  stupefaction.  Soon  after, 
he  could  bear  to  be  moved  from  the  bed  to  the  chair  without 
fatigue ;  the  paralytic  parts  were  rubbed  with  vinegar  and  mus- 
tard, and  he  took  valerian  and  castoreum.  A  cataplasm  of  bread 
and  milk  had  been  daily  applied  to  assuage  the  inflammation 
and  swelling  of  the  eye.  Though  several  large  sloughs  had  been 
thrown  off  from  it,  and  though  the  suppuration  was  in  large  quan- 
tity, yet  the  bulk  of  the  parts  did  not  diminish,  nor  the  inflamma- 
tion lessen,  till  an  astringent  fotus  of  red  rose-leaves  and  port  wine 
was  applied,  which  so  effectually  braced  up  the  relaxed  parts,  that 
the  lids  came  to  cover  the  deformity.  A  decoction  of  thyme  and 
mustard  was  employed  as  a  gargarisra,  to  remove  the  suppression 
of  voice.  As  soon  as  he  began  visibly  to  mend,  he  had  sometimes 
loud  and  sudden  bursts  of  laughter,  and  at  other  times  a  long-con- 
tinued silent  simpering,  a  species  of  convulsion  not  unlike  that  cal- 
led by  the  Greek  physiciansj  Kwim  c^cto-fMi.     When  he  attempt- 


11 

ed  to  walk,  he  had  such  gestures  as  accompany  St.  Vitus 's 
dance,  and  seemed  a  perfect  idiot,  throwing  eagerly  forward  one 
leg,  and  dragging  the  other  trembling  after.  At  the  time  when 
Mr.  Geach  drew  up  his  account  of  the  case,  the  patient's  appetite 
was  natural,  his  sleep  sound  and  refreshing,  his  hearing  acute  ;  he 
spoke,  but  drawled  out  his  words  rather  indistinctly  than  articu- 
lately ;  the  paralytic  arm  and  thigh  were  again  animated,  and 
were  recovering,  but  slowly,  their  power  of  flexion  and  extension. 
He  remembered  nothing  from  the  moment  he  had  received  the  in- 
jury to  the  time  he  recovered  and  sat  up.* 

The  only  comment  which  I  think  it  necessary  to  make  on  this 
interesting  case  is,  that  the  instantaneousness  with  which  the  pa- 
tient fell  on  receiving  the  injury,  looks  very  like  the  efTect  of  a 
wound  of  the  brain  ;  while,  on  the  other  hand,  the  slowness  of  the 
pulse  and  the  hemiplegia,  are  more  the  symptoms  of  pressure  from 
effused  blood.  Even,  however,  on  the  supposition  that  the  small- 
sword had  not  penetrated  through  the  ethmoid  bone  into  the  brain, 
the  case  becomes  only  the  more  remarkable ;  as  on  that  supposi- 
tion, it  would  lead  us  to  conclude,  that  a  wound  of  the  bones  of  the 
orbit,  without  perforation,  might  be  attended  by  rupture  of  vessels 
within  the  cranium,  and  consequently  with  pressure  on  the  brain, 
and  paralysis. 

5.  Foreign  body  siill  in  the  orbit.  In  all  the  instances  which 
I  have  hitherto  quoted,  the  weapon,  whatever  it  was,  was  instantly 
withdrawn  on  the  injury  being  inflicted ;  but  we  must  be  prepared 
to  meet  with  cases  where  the  foreign  body,  which  has  been  driven 
through  the  walls  of  the  orbit,  still  remains  in  the  wound. 

In  such  cases,  we  instantly  proceed  to  its  removal  ;  for  there 
very  soon  follows  such  a  degree  of  swelhng,  as  might  prevent  us 
from  accomplishing  the  extraction  without  great  difficulty,  if  at  all  j 
and  if  the  weapon  was  left,  what  could  we  expect,  but  destructive 
inflammation  of  the  eyeball,  of  the  orbit,  of  the  surrounding  parts, 
and  among  these,  of  the  brain  ? 

A  labourer  thrust  a  long  lath,  with  great  violence,  into  the  inner 
canthus  of  the  left  eye  of  another  labourer.  It  broke  off  quite  short, 
so  that  a  piece,  nearly  two  inches  and  a  half  long,  half  an  inch 
w4de,  and  above  a  quarter  of  an  inch  thick,  remained  in  his  head, 
and  was  so  deeply  buried,  that  it  could  scarce  be  seen,  or  laid  hold 
of.  He  rode  with  the  piece  of  lath  in  him  above  a  mile,  to  Barnet, 
where  Mr.  Morse,  a  surgeon,  extracted  it  with  difficulty ;  it  sticking 
so  hard,  that  others  had  been  baffled  in  attempting  to  remove  it. 
The  man  continued  dangerously  ill  for  a  long  time  ;  at  last  he  re- 
covered entirely,  with  the  sight  of  the  eye,  and  the  use  of  its  mus- 
cles ;  but  even  after  he  seemed  well,  upon  leaning  forwards,  he 
felt  great  pain  in  his  head.t 

In  the  days  when  javelins  and  arrows  formed  principal  weapons 

*  Philosophical  Transactions  for  1763 ;  Vol.  liii.  p.  234. 
t  Philosophical  Transactions  for  1748;  Vol.  xlv.  p.  520. 


12 

of  war,  many  difficult  cases  of  this  sort  must  have  occuiied.  Albii- 
casis  shortly  relates  two^  which  had  come  under  his  care.  In  the 
one,  the  arrow  entered  at  the  nasal  side  of  the  orbit,  and  was  ex- 
tracted under  the  ear.  The  patient  recovered,  without  any  per- 
manent injury  of  the  eye.  In  the  other  case,  a  Jew  was  struck 
with  a  large  un barbed  arrow  from  a  Turkish  bow,  under  the  lower 
eyelid.  It  had  sunk  so  deep,  that  Albucasis  could  reach  with  diffi- 
culty the  end  of  the  iron,  wiiere  it  stuck  upon  the  shaft.  This 
patient  also  recovered  without  any  serious  effect.* 

Yery  great  force  may  sometimes  be  necessary  for  extracting  a 
foreign  body,  which  has  been  driven  through  the  walls  of  the  orbit. 
Fare's  successful  case  is  well  known,  when  he  was  obliged,  with  a 
pair  of  farrier's  pincers,  to  tear  away  from  the  Duke  of  Guise,  the 
broken  end  of  an  English  lance,  which  had  entered  above  the 
right  63^6,  and  towards  the  root  of  the  nose,  and  had  penetrated  as 
far  as  the  space  between  the  ear  and  the  nape  of  the  neck,  tearing 
and  destroying  vessels  and  nerves  in  its  course,  as  well  as  fracturing 
the  bones.t 

Percy  had  under  his  care  a  fencing-master,  w^io,  in  an  assault, 
received  so  furious  a  blow  from  a  foil  on  the  right  eye,  that  the 
weapon  penetrated  nearly  half  a  foot  into  the  head,  and  broke  short. 
The  man  fell  down  in  a  state  of  insensibility,  and  very  soon  the 
supervening  swelUng  was  so  great  as  to  conceal  the  foreign  body. 
In  order  to  lay  hold  of  it,  Percy  opened  and  evacuated  the  con- 
tents of  the  eyeball.  His  forceps  not  being  strong  enough,  he  sent 
to  a  clock-maker  in  the  neighbourhood,  and  borrowed  from  him  a 
pair  of  screw-pincers,  with  w^hich  he  laid  hold  as  tightly  as  possible 
of  the  broken  end  of  the  foil,  and  thus  succeeded  in  extracting  it. 
The  fencing-master  died  some  weeks  after,  more  from  the  conse- 
quences of  intemperance  than  of  the  injury.  Commenting  on  this 
case,  Percy  recommends  that  we  should  rather  remove  the  eyeball, 
than  leave  large  foreign  bodies  in  such  a  situation  ;  and  refers,  in 
support  of  this  practice,  to  a  case  related  by  Bidloo,  in  which  a 
splinter  of  wood  was  left  to  come  away  from  the  orbit  b)^  suppura- 
tion. The  eye  burst  at  last,  after  the  most  dreadful  pain,  and  after 
the  other  eye  had  been  threatened  w4th  destructive  sympathetic  in- 
flammation.+ 

Sabatier  notices  a  case  of  wound  with  a  knife,  through  the  upper 
eyelid,  which  also  tore  the  neighbouring  edge  of  the  frontal  bone. 
It  was  not,  he  says,  till  after  four  hours'  work,  that  the  surgeon 
succeeded,  by  means  of  a  hand-vice,  in  tearing  away  the  portion 
of  the  knife-blade,  which  remained  in  the  orbit,  on  account  of  its 
projecting  so  little  from  the  wound.  The  patient  complained  of 
severe  pain,  as  if  one  had  been  tearing  out  his  eye.     No  ill  conse- 

*  Albucasis  Methodus  Medendi;  Lib.  ii.  cap.  xciv.  p.  166.     Easileae,  1541. 

t  Pare,  Apologie  et  Voyages ;  Voyage  de  Boulogne,  1545. 

t  Percy,  Manuel  du  Chirurgien-d'Armee,  p.  HI.     Paris,  1792. 


13 

quetice  followed  ;  the  cure  was  speedy,  and  without  any  affection 
of  sight.* 

6.  Dangers  after  the  foreign  body  is  removed.  We  must  not 
'  imagine  that  on  withdrawing  the  foreign  body  from  the  orbit,  the 
danger  is  over.  Inflammation,  even  fatal  inflammation  may  fol- 
low, as  in  the  case  I  have  just  quoted  from  Percy  ;  nay,  the  patient 
has  been  known  suddenly  to  expire,  immediately  after  the  foreign 
body  was  removed. 

A  girl,  10  years  of  age,  playing  along  with  other  children,  near 
a  cotton-spinning  machine,  fell  upon  one  of  the  pointed  iron  spikes, 
5  or  6  inches  long,  on  which  the  bobbin  is  placed.  This  instru- 
ment penetrated  to  the  depth  of  about  2  inches  into  the  orbit,  be- 
tween the  inner  wall  and  the  globe  of  the  eye,  and  then  broke 
across  so  that  2  or  3  lines'  length  of  it  projected  above  the  level 
of  the  skin.  Attempts  were  made  to  remove  it,  but  so  much  diffi- 
culty was  experienced  that  these  attempts  were  not  persisted  in. 
Ten  days  afterwards,  the  piece  of  iron  was  found  protruded  for  the 
length  of  9  or  10  lines  ;  a  month  afterwards,  it  was  still  more  protrud- 
ed :  in  fact,  it  now  held  apparently  so  shghtly,  that  it  was  laid  hold 
of  with  the  fingers,  and  extracted.  Scarcely  had  this  been  done, 
when  the  child  was  seized  with  convulsions,  and  died  in  a  quarter 
of  an  hour.  The  sight  had  not  been  affected  during  the  residence 
of  the  foreign  body  in  the  orbit,  nor  had  its  presence  there  excited 
any  very  marked  symptoms.  The  child  had  always  been  able  to 
go  about.t 

7.  Eyeball  dislocated.  It  is  important  to  observe,  that  mention 
is  made  bj?^  various  surgical  authors,  of  the  eyeball  being  dislocated, 
or  pushed  out  of  its  socket,  by  a  foreign  body  thrust  into  the  cavity, 
or  traversing  the  sides  of  the  orbit.  Now,  in  such  cases,  it  is 
necessary  not  only  to  remove  the  foreign  body,  but  to  reduce  the 
eye.  This  has  sometimes  been  done  with  complete  restoration  of 
vision. 

By  being  dislocated,  or  pushed  out  of  its  socket,  is  to  be  under- 
stood, that  the  eyeball  is  extruded  beyond  the  fibrous  layer  of  the 
eyelids  ;  that  layer  which  is  a  continuation  of  the  periosteum,  and 
lies  beneath  the  orbicularis  palpebrarum.  Of  course,  the  optic 
nerve  must  be  put  very  much  on  the  stretch  by  such  an  accident, 
and  the  eyelids  can  no  longer  be  made  to  close  upon  the  protruded 
eyeball. 

Mr.  B.  Bell  relates  a  case,  in  which  the  eye  was  almost  com- 
pletely turned  out  of  the  socket,  by  a  sharp  pointed  piece  of  iron 
pushed  in  beneath  it.  The  iron  passed  through  a  portion  of  the 
orbit,  and  remained  very  firmly  fixed  for  the  space  of  a  quarter  of 
an  hour,  during  which  period  the  patient  suffered  exquisite  pain. 
He  saw  none  with  the  dislocated  eye  ;  and  the  protrusion  being  so 

*  Sabatier  de  la  Medecine  Operatoire.  Tome.  i.  p.  409     Paris,  1822. 

t   Demours,  traite  des  Maladies  des  Yeux.     Tome  ii.  p.  45.  Paris,  1818. 


14 

great  as  to  lead  to  the  suspicion  that  the  optic  nerve  was  ruptured, 
Mr.  Bell  doubted  whether  it  would  answer  any  purpose  to  replace 
it.  He  found,  however,  on  removing  the  wxdge  of  iron,  which 
being  driven  to  the  head,  was  done  with  difficulty,  that  the  power 
of  vision  instantly  returned,  even  before  the  eye  was  replaced. 
The  eye  was  now  easily  reduced  to  its  original  situation,  inflam- 
mation was  guarded  against,  and  the  patient  enjoyed  perfect 
vision.* 

8.  Foreign  body  not  removed.  The  foreign  body,  by  which 
a  wound  of  the  orbit  has  been  inflicted,  has  in  some  cases  been 
left  unremoved,  from  the  fact  of  its  presence  not  having  been  sus- 
pected, or  from  the  surgeon  not  having  instituted  a  suflficiently 
strict  examination  of  the  wound  with  the  probe ;  while,  in  other 
cases,  it  has  been  left  in  the  orbit  or  in  the  cranium,  from  an  im- 
possibility of  removing  it  v/ith  safety. 

I  do  not  recollect  to  have  met,  in  the  course  of  my  reading,  with 
any  case  of  a  foreign  body  thrust  through  the  orbit  by  mere  man- 
ual force,  and  left  within  the  cranium.  Numerous  cases  of  gun- 
shot v/ounds,  however,  in  which  the  ball  or  other  foreign  body  was 
left  within  the  cranium,  are  recorded ;  and  it  is  evident  that  the 
eflfects,  so  far  as  the  mere  presence  of  the  foreign  body  is  concerned, 
must  be  much  the  same,  whether  it  has  passed  through  the  orbit 
into  the  brain  by  manual,  or  by  gunshot  force.  Death,  under  such 
circumstances,  is  almost  certain  to  be  the  result,  either  immediately 
or  in  the  course  of  a  few  days ;  although  some  remarkable  cases 
have  happened  of  extraneous  bodies  lying  for  years  in  the  very 
brain  itself,  without  producing  death,  or  causing  any  apparent  in- 
convenience.! 

As  to  foreign  bodies,  which  have  merely  passed  through  one  or 
other  of  the  sides  of  the  orbit,  and  are  left  without  removal,  they 
give  rise  to  more  or  less  irritation,  destroy  the  bones  more  or  less 
extensively,  take  different  routes  for  their  escape,  but  in  most  in- 
stances appear  to  pass  either  through  the  maxillary  sinus,  or  by  the 
spheno-raaxillary  fissure  into  the  fauces,  and  are  discharged  in  very 
various  spaces  of  time. 

Marchetti  tells  us,  that  he  had  under  his  care  a  beggar,  who, 
asking  charity  rather  importunately  one  summer  day  from  a  Pa- 
duan  nobleman,  this  testy  personage  struck  the  beggar  with  the 
handle  of  his  fan,  in  the  inner  angle  of  the  eye,  and  with  so  much 
force,  that  a  portion  of  the  fan.  three  inches  long,  broke  through 
the  orbit,  and  sunk  out  of  sight  in  the  direction  of  the  palate. 
When  the  man  came  to  the  hospital,  Marchetti  removed  some 


*  Bell's  System  of  Surgery;  Vol.  iv.  p.  162.  Edinburgh.  1801.— The  author  of 
the  Dictionaire  Ophthalmologique  has  entirely  misunderstood  this  case ;  he  tells  us 
that  the  optic  nerve  was  wounded  (Ires  blesse),  which  forms  no  partiof  Mr.  Bell's 
statement ;  and  very  improperly  throws  doubts  upon  that  gentleman's  veracity.  '  , 

t  See  GLuesnay's  paper  on  Wounds  of  the  Brain,  in  the  Memoirs  of  the  French  i| 
Academy  of  Surgery.  '" 


15 

small  bits,  which  he  found  sticking  in  the  angle  of  the  eye,  com- 
bated the  inflammation,  allowed  the  wound  to  close,  and  dismissed 
the  patient  as  cured.  In  three  months,  he  returned  with  a  large 
sweUing  in  the  palate,  which,  when  Marchetti  cut  into,  his  knife 
struck  upon  the  handle  of  the  fan,  which  he  immediately  extracted 
with  a  pair  of  forceps.     The  patient  speedily  recovered.* 

Mr.  White  relates  the  case  of  a  person,  to  whom  it  happened, 
that,  as  he  sat  in  company,  the  small  end  of  a  tobacco-pipe  was 
thrust  through  the  middle  of  the  lower  eyelid.  It  passed  between 
the  globe  of  the  eye  and  the  inferior  and  external  circumference 
of  the  orbit,  and  was  forced  through  that  portion  of  the  os  maxillare, 
which  constitutes  the  lower  and  internal  part  of  the  orbit.  The 
pipe  was  broken  in  the  w^ound,  and  the  part  broken  off,  which, 
from  the  examination  of  the  remainder,  appeared  to  be  above  three 
inches,  was  quite  out  of  sight  or  feeling,  nor  could  the  patient  give 
any  account  of  what  had  become  of  it.  The  eye  was  dislocated 
upwards,  pressing  the  upper  eyelid  against  the  superior  part  of  the 
orbit ;  the  pupil  pointed  perpendicularly  upwards,  the  depressor 
ocuh  was  upon  the  full  stretch,  and  the  patient  could  see  none  with 
that  eye.  Mr.  W.  apphed  one  thumb  above  and  the  other  below 
the  eye,  and  after  a  few^  attempts  at  reduction,  it  suddenly  slipped 
into  its  socket.  The  man  instantly  recovered  perfect  sight,  and 
felt  no  other  inconvenience  than  that  of  a  constant  smell  of  tobacco 
smoke  in  his  nose  for  a  long  time  after  ;  for,  as  he  informed  Mr. 
W.,  the  pipe  had  just  been  used  before  the  accident.  About  two 
years  afterwards,  he  called  on  Mr.  W.  to  acquaint  him,  that  he  had 
that  morning,  in  a  fit  of  coughing,  thrown  out  of  his  throat  a  piece 
of  tobacco-pipe,  measuring  two  inches,  which  was  discharged  with 
such  violence,  as  to  be  thrown  seven  yards  from  the  place  where  he 
stood.  In  about  six  weeks,  he  threw  out  another  piece  measuring 
an  inch,  in  the  same  manner,  and  never  afterwards  felt  the  least 
inconvenience.t 

In  illustration  of  the  great  length  of  time  which  a  foreign  body 
may  take  in  this  way  to  escape,  1  may  notice  the  following  case, 
related  in  a  letter  to  Horstius.  A  boy  of  14  years  of  age  was  struck 
by  an  arrow,  while  amusing  himself  in  his  play-ground.  It  stuck 
fast  in  the  orbit,  but  the  boy  pulled  it  out,  and  threw  it  on  the  ground. 
A  surgeon  arrived,  to  whom  the  playfellows  of  the  boy  who  was 
wounded  showed  the  arrow,  deprived  of  its  iron  point.  With  a 
probe  the  surgeon  attempted  to  examine  the  wound  ;  but  on  the 
ijoy  fainting,  he  desisted,  so  that  the  iron  point  w^as  left  in  the  orbit. 
The  external  wound  healed,  and  the  boy  recovered;  the  eye  re- 
mained clear  and  movable,  but  deprived  of  sight.  This  happened 
in  the  beginning  of  August,  1594,  and  nothing  more  was  heard  of 
the  iron  point,  till  October,  1624,  when  after  an  attack  of  fever  and 
catarrh,  with  a  great  deal  of  sneezing,  it  descended  into  the  left 

•  Petri  de  Marchettis  Observationum  Sylloge.     Obs.  23.     Londini,  1729. 
t  Cases  in  Surgery,  by  Charles  White  ;  p.  131.     London,  1770. 


16 

nostril,  whence,  taking  the  way  of  the  fauces,  it  came  into  the 
mouth  and  was  discharged.  During  the  whole  30  years  and  three 
months  that  it  had  remained  in  the  head,  it  had  not  been  produc- 
tive of  any  pain.* 

6.  Incised  Wounds  of  the  Orbit. 

Sabre-wounds  of  the  head  have  sometimes  been  attended  by  a 
cleaving  of  the  orbit ;  and  in  some  rare  instances,  the  orbit  has  ac- 
tually been  laid  open,  either  by  a  very  deep  cut,  or  by  an  entire 
separation  of  part  of  its  parietes.  The  following  cases  are  sufficient 
illustrations  of  this  class  of  injuries  of  the  orbit. 

Marchetti  shortly  states  the  case  of  a  German  soldier,  who  was 
wounded  in  the  forehead  with  a  broad  and  heavy  sword.  The 
frontal  bone  and  the  brain  were  divided,  down  to  the  eyes,  and  the 
patient  was  immediately  deprived  of  sight.  In  two  months,  he  re- 
covered from  the  wound,  but  continued  blind,  with  the  pupils  clear.t 

The  following  case  shows  the  propriety  of  attempting  union  by 
the  first  intention,  even  when  a  piece  of  the  osseous  parietes  of  the 
orbit  is  completely  separated  by  an  incised  wound. 

M.  Ribes  was  called  to  a  young  man  who  had  received  a  wound 
with  a  cutting  instrument,  extending  obliquely  from  the  upper  part 
of  the  left  temporal  fossa  across  the  root  of  the  nose,  to  the  right 
fossa  canina.  This  wound  had  divided  the  skin,  the  temporal 
branches  of  the  7th  pair  of  nerves,  the  anterior  auricular  muscle,  a 
part  of  the  temporal  muscle,  orbicularis  palpebrarum,  and  corruga- 
tor  supercilii.  the  frontal  branch  of  the  opthalmic  nerve,  and  the 
superciliary  artery.  These  parts  hanging  over  on  the  cheek,  formed 
a  flap,  in  which  were  also  present  a  portion  of  the  orbitary  arch  of 
the  frontal  bone  and  its  external  angular  process,  so  that  a  portion 
of  the  cavity  of  the  cranium  was  laid  open,  as  well  as  the  cavity  of 
the  orbit,  exposing  to  view  the  globe  of  the  eye,  and  the  motion  of 
the  brain.  The  nasal  nerve  and  artery,  the  pyramidal  muscles, 
and  in  a  shght  degree  the  bones  of  the  nose,  were  divided  ;  from 
the  nose  to  the  right  fossa  canina,  only  the  skin  was  divided.  The 
portion  of  brain  laid  bare  appeared  unhurt:  the  eye  also  seemed 
perfectly  sound,  none  of  its  parts  had  been  touched,  except  the  lev- 
ator palpebree  superioris,  which,  having  been  cut  across  in  the  mid- 
dle, presented  its  anterior  half  in  a  state  of  relaxation,  and  dragged 
downwards  and  forwards  by  the  flap  which  lay  upon  the  cheek. 
The  patient  had  neither  experienced  any  concussion,  nor  become 
insensible ;  but  when  M.  R.  saw  him,  was  in  a  state  of  considera- 
ble depression.  A  surgeon,  who  had  been  called  before  M.  R. 
arrived,  had  already  dressed  the  wound.  Perhaps,  in  imitation  of 
Magatus,  who  directs  in  such  cases  that  a  plate  of  gold  or  lead, 
drilled  through  with  holes,  be  applied  over  the  dura  mater,  and  that 

*  Gregorii  Horstii  Observationum  Lib.  i.  Operum  Tom.  ii.  p.  225.     rsorimbergEe, 
1660. 
t  Petri  de  Marchettis  Observationum  Sylloge.     Obs.  17.     Londini,  1729. 


17 

the  edges  of  the  wound  be  simply  brought  together,  without  sup- 
porting them  by  sutures,  this  surgeon  had  placed  between  the  lips 
of  the  wound  a  bit  of  hnen  spread  with  cerate  on  both  sides,  in  or- 
fder  to  give  vent  to  the  suppuration,  which  no  doubt  would  have 
followed ;  he  had  then  brought  the  flap  into  its  place,  and  supported 
it  by  a  roller.  M.  R.  removed  the  piece  of  linen,  and  brought  the 
edges  of  the  wound  exactly  together,  retaining  them  by  strips  of 
adhesive  plaster.  In  six  weeks,  the  patient  was  cured,  without 
fever  or  suppuration.  The  eye,  however,  which  had  been  exposed 
became  blind,  and  the  upper  eyelid  remained  motionless.  Ten 
years  afterwards,  the  eye  still  preserved  its  form  and  transparency, 
but  had  shrunk  in  size.  M.  R.  is  of  opinion,  that  the  blindness  in 
this  case  was  a  sympathetic  effect,  produced  upon  the  retina  by  the 
division  of  the  brandies  of  the  5th  pair.  He  regards  the  retina,  not 
;is  a  mere  expansion  of  the  optic  nerve,  but  as  a  nervous  membrane 
into  which  enter  branches  of  the  great  sympathetic,  and  of  the  cil- 
iary or  iridal  nerves,  as  well  as  the  fibrils  of  the  optic  nerve ;  whence 
injuries  of  the  great  sympathetic  or  of  the  5th  pair  produce  blind- 
ness, althoug-h  in  the  first  instance  the  optic  nerve  may  not  be  at 
all  affected.*' 

Although  the  separated  piece  of  the  orbit  appears  to  have  united  ■ 
in  this  case,  it  sometimes  happens  that  only  the  soft  parts  unite, 
while  the  bones  continue  divided.  Of  this,  we  have  an  example  in 
the  case  related  by  Dr.  Hennen,  of  an  officer,  who,  at  the  battle  of 
Waterloo,  received  a  sabre-wound  across  the  eyes,  cutting  obliquely 
inwards  and  downwards  to  such  a  depth  as  to  admit  of  a  view  of 
the  pharynx.  One  eye  was  destroyed,  and  the  hiatus  was  so  great, 
that  the  upper  jaw  was  obliged  to  be  supported  by  morsels  of  cork 
put  into  the  mouth,  in  such  a  way  as  to  act  as  fulcra,  but  admitting 
the  passage  of  liquid  nourishment.  After  the  wound  was  dressed 
on  the  field,  the  patient  was  sent  to  Brussels,  where  he  fell  into  the 
hands  of  a  Belgian  barber,  who  stupidly  cut  out  the  hgatures,  re- 
moved the  straps  by  which  the  lower  portion  of  the  face  was  kept 
in  position,  and  stuffed  the  parts  with  charpie.  This  was  not  re- 
moved for  several  days,  after  which  the  parts  v/ere  again  brought 
into  apposition  by  straps  and  bandages,  but  with  great  pain,  and 
consequent  delirium.  The  patient  recovered,  granulations  sprout- 
ing up  at  all  points,  and  the  soft  parts  uniting,  but  not  the  bones.t 

7.   Gunshot  Wounds  of  ike  Orbit 

"Present  much  greater  variety  in  their  direction  than  any  other 
wounds  of  this  part.  They  also  vary  much  in  the  depth,  extent, 
and  effects  of  the  injury  which  they  produce. 

1.  Exterior  parts  of  orbit  injured.     The  superciliary  ridge, 

*  Meraoires  de  la  Societe  Medicale  d'Emulation;  Vol.  vii.  p.  86.     Paris,  1811. 
t  Hennen's  Observations  on  some  important  points  in  Military  Surgery;  p.  370. 
Edinburgh,  1818. 


18 

and  tlie  other  exterior  parts  of  the  orbit,  are  often  the  seat  of  gun- 
shot injuries. 

Sometimes  a  ball  will  traverse  the  outer  wall  of  the  orbit ;  in 
other  cases,  it  will  pass  through  the  superciliary  ridge.  When  the 
latter  is  the  case,  the  ball  generally  descends  afterwards  through 
the  floor  of  the  orbit  into  the  maxillary  sinus,  or  into  the  nostril, 
destroying  the  eyeball  in  its  course.  The  frontal  sinus,  when  much 
expanded,  separates  the  two  tables  of  the  orbitary  plate  of  the  fron- 
tal bone,  so  as  to  form  a  cavity,  in  w^hich  musket  balls  have  fre- 
quently been  known  to  lodge.  This  is  generally  attended  by  de- 
pression of  the  inner  table,  so  as  to  render  necessary  the  operation 
of  trepan.  The  surgeons  of  former  da3rs  refrained  from  trepanning 
these  sinuses,  partly  from  fear  of  an  incurable  fistula  following  the 
operation,  partly  from  the  difficulty  of  sawing  through  two  plates  of 
bone  placed  obliquely  in  regard  to  one  another,  without  wounding 
the  dura  mater ;  but  the  fear  of  a  fistula  is  now  laid  aside,  and  the 
second  difficulty  is  in  some  degree  removed,  by  employing  two  tre- 
phines, a  large  one  for  the  external,  and  a  small  one  for  the  internal 
table.  In  this  way,  a  depression  may  be  raised,  or  a  ball,  fixed 
perhaps  in  the  internal  table,  or  in  the  roof  of  the  orbit,  may  be 
removed. 

2.  Bones  of  orbit  susceptible  of  union.  The  bones  of  the  or- 
bit, shattered  by  a  ball,  are  still  in  some  cases,  susceptible  of  union, 
and  ought  not,  therefore,  to  be  too  hastily  removed,  although  they 
are  felt  to  be  loose  after  an  injury  of  this  kind. 

Poneyes  had  under  his  care  a  soldier,  in  whom  a  musket-ball 
had  shattered  the  anterior  part  of  the  frontal  sinuses,  the  upper  part 
of  the  bones  of  the  nose,  and  the  right  orbit  towards  the  inner  an- 
gle. He  fell  instantly  on  receiving  the  wound,  vomited  soon  after, 
became  insensible,  and  bled  at  the  nose.  Poneyes  removed  the 
portion  of  bone  forming  the  frontal  sinuses,  leaving  the  bones  of  the 
nose  and  the  injured  portion  of  the  orbit  loose.  The  posterior  part 
of  the  frontal  sinuses  was  not  fractured.  Delirium  came  on  with 
drowsiness  ;  but  after  the  patient  was  repeatedly  bled,  these  symp- 
toms ceased.  The  loose  pieces  of  bone  reunited,  and  the  cure  was 
completed  in  two  months  and  a  half.* 

3.  Different  directions  of  balls  through  the  orbit.  Balls  pass- 
ing directly  backwards  through  the  orbit,  are  generally  fatal,  from 
entering  the  brain  ;  whereas,  those  w^hich  enter  the  orbit  obliquely, 
though  generally  destructive  of  vision,  either  by  striking  the  eyeball, 
or  dividing  the  optic  nerve,  very  frequently  leave  the  brain  un- 
touched. 

Dr.  John  Thomson,  for  example,  mentions  a  case,  in  which  the 
ball  entered  nearly  in  the  middle  between  the  frontal  sinuses,  passed 
across  the  left  sinus,  and  seemed  to  lodge  in  the  cavity  of  the  orbit, 
producing  bhndness,  with  great  swelling  of  the  eye,  and  of  the  parts 

*  Memoires  del'Academie  de  Chirurgie.    Tome  vi.  p.  202.    12ino.  Paris,  1787. 


19 

surrounding  it.  In  another  case,  where  the  bullet  had  entered  the 
face  on  the  upper  and  left  side  of  the  nose,  and  passed  out  anterior 
to  the  right  ear,  the  patient  was  affected  with  amaurosis  of  the 
right  eye.  The  left  eye  was  similarly  affected,  in  a  case  where  the 
ball  had  entered  the  right  side  of  the  nose,  and  had  come  out  be- 
fore the  left  ear.  In  one  case,  the  ball  had  entered  at  the  inner 
angle  of  the  left  eye,  and  passed  out  before  the  left  ear.  In  another, 
the  ball  had  entered  above  the  inner  angle  of  the  right  eye,  and 
passed  out  of  the  right  ear.  In  both  cases,  the  eye  of  the  side  on 
which  the  ball  had  passed  was  destroyed.  In  one  case,  in  which 
the  ball  had  entered  the  right  eye,  and  had  passed  out  midway  be- 
tween the  left  eye  and  ear,  the  left  eye  was  affected  with  amaurosis.* 

4.  Balls  traversing  both  orbits.  Many  instances  are  recorded 
of  balls  passing  through  both  orbits,  from  temple  to  temple. 

Heister  relates  a  case  of  this  soit.  The  person  recovered  ;  only 
he  became  blind  the  very  moment  he  received  the  shot,  and  re- 
mained so  ever  after.  The  entrance  and  exit  of  the  ball  were  ex- 
actl}'^  in  the  angle  which  the  zygoma  makes  with  the  process  of  the 
malar  bone  going  up  to  join  the  frontal,  and  of  course  the  ball  must 
have  passed  through  the  posterior  part  of  each  orbit,  probably  di- 
viding both  optic  nerves,  without  wounding  either  the  eyeball  or 
the  brain.  The  eyes  appeared  quite  clear,  and  without  inflamma- 
tion, but  fixed,  and  totally  deprived  of  sight.t 

Such  a  gunshot  wound  as  this  must  be  regarded  as  less  danger- 
ous than  one  in  which  the  ball  does  not  pass  so  directly  across  from 
one  side  of  the  head  to  the  other ;  but  either  from  being  directed 
backwards  in  its  course,  enters  the  brain,  or  from  its  force  being 
partially  spent,  lodges  among  the  bones.  Speaking  of  the  wounded 
before  Mons  in  1709,  Heister  states,  that  for  the  most  part,  those 
who  had  received  a  wound  only  in  one  temple,  died  either  imme- 
diately or  soon  after. 

Dr.  Thomson  tells  us,  that  he  saw  from  eight  to  ten  patients, 
after  the  battle  of  Waterloo,  in  whom  musket-balls  had  passed 
through  behind  the  eyes  from  temple  to  temple.  In  all  of  them, 
there  was  great  swelling,  pain,  and  tension  of  the  head  and  face. 
He  mentions,  that  a  careless  examination  would  have  led  one  to 
suppose,  that  in  these  cases  the  balls  had  entered  the  cranium  ;  and 
remarks,  that  cases  of  this  kind  are  recorded,  in  which  the  blind- 
ness which  followed  is  supposed  to  have  been  produced  by  the  balls 
passing  through  the  inferior  part  of  the  anterior  lobes  of  the  brain  ; 
but  that  most  probably  in  such  cases,  the  brain  is  untouched. 

In  one  case  observed  by  Dr.  Thomson,  where  the  ball  had 
passed  through  behind  the  eyes  from  temple  to  temple,  one  eye 
was  destroyed  by  inflammation,  and  the  other  affected  by  amauro- 

*  Thomson's  Report  of  Observations  in  the  Military  Hospitals,  after  the  Battle  of 
Waterloo  ;  p.  64.     Edinburgh,  1816. 

t  Heister's  Medical,  Chirurgical,  and  Anatomical  Cases  and  Observations,  transla- 
ited  by  Wirgnian.     Obs.  Ixxiv.  p. 92.    London,  1755. 


20 

sis.  In  another  case,  wliere  the  ball  had  taken  precisel}^  the  san 
direction,  both  eyes  were  affected  with  amaurosis,  without  ai:i} 
inflammation  being  produced.  He  remarks,  that  in  some  of  the 
patients  in  whom  amaurosis  had  followed,  there  was  reason  to  be- 
lieve, from  the  course  which  the  balls  had  taken,  that  the  optic 
nerves  were  divided  ;  but  that  in  a  considerable  proportion  of  those 
affected  with  amaurosis,  it  was  obvious  that  the  balls  had  not  come 
into  contact  wnth  these  nerves.  Various  instances  occurred,  in 
which  the  bullet,  penetrating  through  both  eyeballs,  had  passed 
behind  the  bridge  of  the  nose,  and  left  it  unbroken.  In  one  of  the 
cases,  in  which  the  ball  had  passed  through  below  and  behind  the 
eyes,  the  patient  was  affected,  at  the  end  of  some  weeks,  with  pain- 
ful spasms  in  the  face,  which,  in  their  severity,  and  in  their  mode 
of  attack,  bore  a  striking  resemblance  to  those  of  tic  douloureux.* 

5.  Balls  sometimes  extracted  from,  the  orbit ;  in  other  cases 
left  unremoved.  A  ball  which  has  penetrated  through  one  or 
other  of  the  sides  of  the  orbit,  may  in  some  cases  be  detected  and 
extracted.  In  other  cases,  it  cannot  be  extracted,  nor  its  course  as- 
certained ;  so  that,  if  the  individual  survives,  it  must  be  left  to 
make  its  waj^  out  by  the  fauces,  or  by  some  other  route. 

In  those  cases  in  which  the  ball  is  left,  we  must  lay  our  account 
with  caries,  exfoliation  of  the  bones,  deep-seated  formations  of  mat- 
ter, sloughing  of  the  mucous  membranes,  puffy  swellings  on  the 
surface  towards  which  the  ball  is  approaching,  and  a  very  tedious 
recovery.  Sinuses  form,  in  such  cases,  before  the  ball  makes  its 
exit,  and  continue  after  it  has  escaped  ;  and  to  dry  these  up  is  gen- 
erally attended  with  danger.  We  must  wait  till  the  parts  within 
have  become  healthy,  and  then  the  sinuses  will  close  of  themselves 

Dr.  Hennen  mentions  the  case  of  a  soldier,  who  was  brought  tc 
him  some  weeks  after  being  wounded,  for  the  purpose  of  having  e 
ball  extracted,  which  gave  him  excessive  pain,  impeded  his  respi 
ration  and  deglutition,  prevented  his  speaking  distinctly,  and  kejjl 
up  an  irritation  in  his  fauces,  attended  with  a  constant  flow  of  sal 
iva,  and  a  very  frequent  inclination  to  vomit.  On  examination,  i) 
was  found  to  be  lodged  in  the  posterior  part  of  the  fauces,  forming 
a  tumour  behind,  and  nearly  in  contact  with  the  velum  pendulum 
It  had  passed  in  at  the  internal  canthus  of  the  eye,  fracturing  the 
bone.  Although  blindness  was  the  instant  consequence,  the  globe 
of  the  eye  was  not  destroyed  ;  and  the  remaining  cicatrice,  and  the 
very  inflamed  state  of  the  organ,  were  the  only  proofs  that  an  ex 
traneous  body  had  passed  near  it.*" 

One  of  the  most  remarkable  cases  of  a  ball  which  had  penetratec 
through  the  orbit  making  its  way  out  of  the  head,  is  that  of  Dr 
Fielding,  who  was  shot  at  the  battle  of  Newberry,  in  the  time  o 
the  Civil  Wars.     The  ball  entered  by  the  right  orbit,  and  passec 

*  Thomson's  Report  of  Observations,  &c.  p.  G5. 

t  Hennen's  Observations  on  some  important  points  in  Military  Surgery ;  p.  361' 
Edin.  1818. 


21 

nwards.  After  30  years'  residence  in  the  parts,  and  a  variety  of 
I  exfoliations  from  the  wound,  nose,  and  mouth,  and  the  formation 
;)f  several  swellings  about  the  jaw,  it  was  at  last  cut  out  near  the 
jDomum  Adami.* 

6.  Balls  or  other  foreign  bodies  passing  through  the  orhit, 
\eft  within  the  crajiiuni.  Although  it  generally  happens  that 
Tunshot  wounds  of  the  orbit,  penetrating  into  the  brain,  prove  im- 
mediately mortal,  yet  in  some  rare  cases,  the  ball,  or  other  foreign 
body,  has  been  known  to  remain  within  the  cranium  for  a  length 
of  time,  without  producing  much  disturbance. 

Petit  related  in  his  lectures,  the  case  of  a  soldier,  who  received  a 
musket-shot  in  the  inner  angle  of  the  eye.  It  seemed  a  very  sim- 
ple wound,  and  healed  under  the  common  hospital  treatment. 
The  man  seeing  himself  cured,  determined  to  leave  the  hospital, 
although  advised  by  the  surgeon  to  remain  some  time  longer. 
Scarce  had  he  reached  the  door,  when  he  was  seized  with  rigors, 
obliged  to  return,  and  died  in  two  days.  On  dissection,  the  ball 
was  found  lodged  under  the  sella  turcica  and  optic  foramina.  An 
abscess  was  present  in  the  brain.t 

Dr.  Hennen  mentions  the  case  of  a  French  soldier,  wounded  at 
Waterloo.  The  ball  entered  the  right  eye  ;  the  left,  though  not  in 
the  slightest  degree  injured  to  appearance,  was  completely  blind. 
Dr.  H.  felt  under  the  zygoma,  and  all  along  the  neighborhood  of 
the  wound,  but  in  the  puffy  state  of  the  parts  could  not  detect  the 
course  of  the  ball.  The  patient  himself  was  confident  it  had  gone 
into  his  brain.     He  returned  to  France  convalescent.  + 

The  following  case  of  a  gun-breech  penetrating  the  orbit  and 
cranium,  and  remaining  in  the  brain  for  two  months  previously  to 
the  death  of  the  patient,  occurred  to  Mr.  Waldon  of  Great  Torring- 
ton,  Devon,  and  was  communicated  by  Mr.  Abernethy  to  the  Med- 
ical Society  of  London.  A  lad,  of  19  years  of  age,  about  5  o'clock 
in  the  afternoon,  as  he  was  shooting  at  a  wood-dove,  was  knocked 
down  in  consequence  of  the  bursting  of  the  gun.  No  person  being 
with  him  at  the  time,  the  first  effects  of  the  injury  could  not  possi- 
bly be  ascertained  ;  he  was  probably  deprived  of  sensation  and 
power  by  the  accident,  as  he  remained  in  the  wood  until  the  after- 
noon of  the  following  day,  comprising  a  space  of  22  hours,  during 
a  very  severe  frost,  and  was  found  about  60  paces  from  the  spot 
where  the  accident  happened.  On  Mr.  W.'s  arrival,  he  found  the 
patient  in  his  perfect  senses,  notwithstanding  that  the  os  frontis  and 
dura  mater  had  been  perforated  a  little  on  the  right  side  and  above 
the  frontal  sinus,  and  that  a  considerable  quantity  of  the  cerebrum 
was  then  upon  his  clothes,  and  exuding  from  the  wound.  From 
considering  the  nature  of  the  injury,  and  the  manner  in  which  it 

*  Philosophical  Transactions,  abridged  by  Jones.     Vol.  v.  p.  203. 
t  Garengeot,  Traite  des  Operations  de  Chirurgie ;  Tome  iii.  Obs.  xx.  p.  155, 
Paris,  17.31. 
t  Hennen's  Observations,  &c.  p.  361. 


22 

had  been  inflicted.  'Mi.  "W.  concluded  that  only  the  breech,  as  it  i- 
called.  which  screws  into  the  back  part  of  the  barrel  of  the  gun. 
could  have  effected  the  mischief.  On  the  gun  being  found,  his 
conclusion  was  verified,  the  barrel  being  perfect,  and  the  breech 
gone,  having  carried  with  it  the  whole  of  the  wooden  part  of  tl.e 
stock  on  a  plane  with  itself.  Notwithstanding  he  was  at  this  time 
sensible.  Mr.  W.  still  doubted,  from  toe  force  with  which  the  breech 
must  have  been  dislodged  from  the  barrel,  to  overcome  the  resist- 
ance of  the  OS  frontis  and  dura  mater,  whether  it  might  not  be 
within  the  cavity  of  the  cranium.  In  the  most  gentle  manner 
possible,  he  introduced  his  finger  as  far  as  he  judged  it  prudent,  in 
order  to  detect  whether  any  extraneous  body  was  lodged  there  or 
not.  but  without  efiect.  The  patient  having  lost  a  considerable 
quantity  of  blood,  as  appeared  on  examining  the  spot  where  he  lay 
the  preceding  night.  Mr.  TT.  judged  it  not  expedient  to  open  a  vein, 
but  contented  himself,  for  that  night,  with  wrapping  the  upper  part^ 
of  the  face  in  a  warm  poultice,  giving  a  laxative  mixture,  and  or- 
dering a  strict  antiphlogistic  regimen.  Next  morning,  !Mr.  W..  to  ' 
his  inexpressible  surpiise.  was  informed  that  the  lad  had  passed  a 
good  night-  retained  his  senses,  and  was  in  good  spirits.  On  re- 
moving the  cataplasm,  he  found  that  an  immense  discharge'of  bloody 
fluid  had  exuded  from  the  cavity  of  the  cranium.  This  continued 
for  several  days  to  be  thrown  out.  to  the  quantity  of  at  least  a  pint 
every  24  hours,  by  the  pulsatory  motion  of  the  arteries.  On  re- 
moving, at  the  first  dressing,  some  part  of  the  cataplasm  from  the 
internal  canthus  of  the  left  eye.  3lr.  "W.  discovered  by  the  probe, 
the  head  of  one  of  the  screw  pins  which  fastens  the  lock  to  the 
stock,  almost  buried  beneath  the  inflamed  integuments,  and  which 
had  penetrated  the  roof  of  the  orbit  upwards  and  backwards,  through 
the  cerebrum,  towards  the  right  parietal  bone.  3Ir.  W.  extracted 
the  nail  with  some  difiiculty.  From  the  figure  which  he  has  given 
of  it,  it  appears  to  have  been  the  breech  nail,  an  inch  and  three 
Cjuarters  long,  a  quarter  of  an  inch  thick,  bent  at  an  angle  of  about 
135°.  For  some  days,  few  or  no  unfavorable  symptoms  occurred, 
but  a  temporary  loss  of  the  power  of  associating  ideas.  The  pa- 
tient did  not  immediately  recollect  himself  when  awaking  from 
sleep.  The  discharge  continued  profuse.  On  the  morning  of  the 
7th  day  from  the  time  of  the  accident,  Mr.  W.  was  alarmed  by  the 
coming  on  of  drowsiness,  stertorous  breathing,  and  sinking  of  the 
pulse  from  70  to  .5.5.  Under  these  unfavorable  circumstances,  he 
ordered  the  fomentations  to  be  renewed,  and  made  large  evacua- 
dous.  ZS'ext  morning,  the  patient  was  greath'  better ;  and  from 
this  period,  his  convalescence  became  apparent  daily.  The  tension 
of  the  integuments  subsided,  the  pain  of  the  head,  hitherto  violent 
and  almost  insupportable,  left  him.  and  laudable  pus  was  evacuated 
through  the  opening  in  the  frontal  bone.  In  this  state,  he  visited 
Mr.  T\  .'s  house,  about  the  distance  of  2  miles,  every  day.  or  every 
other  dav,  sometimes  on  horseback,  oftener  on  foot,  to  have  his  ' 


2S 

^i  head  dressed,  without  the  least  apparent  fatigue  or  inconvenience. 
;  Precisely  in  this  state  he  continued  till  the  20th  of  January,  (the 
accident  having  happened  on  the  29th  of  November,)  when  he  had 
ia  severe  rigor,  and  complained  of  great  pain  in  the  back  part  of  his 
head  and  muscles  of  the  neck,  with  total  loss  of  appetite,  and  ina- 
'  bility  to  quit  his  bed.  He  had  gone  to  a  feast  in  the  neighborhood, 
where  he  had  indulged  more  in  eating  and  drinking  than  Avas 
proper.  Previously  to  this,  nature  appeared  to  be  regenerating 
■the  lost  cerebrum,  throwing  out  from  its  substance  granulations  of 
a  faint  blush  color.  The  symptoms  of  inflammation  and  formation 
of  pus  within  the  cranium  continued  to  increase  till  the  28th,  when 
!  he  was  taken  sick.  During  the  act  of  vomiting,  the  attendants 
I  perceived  on  a  sudden,  a  large  projection  on  the  right  side  of  the 
:  frontal  bone,  underneath  the  sound  integuments,  and  about  2 
inches  from  the  wound.  On  examination,  Mr.  W.  thought  he 
[perceived  a  large  portion  of  the  frontal  bone  detached,  and  in  a  state 
of  exfoliation  ;  and  considered  a  free  division  of  the  integuments, 
and  a  total  removal  of  the  substance,  whatever  it  might  be,  as  af- 
fording his  patient  the  only  chance  of  recovery.  As  he  was 
dividing  the  integuments,  which,  extraordinary  as  it  may  appear, 
were  scarcely  altered  from  a  natural  state,  he  perceived  the  knife  to 
grate  on  a  yielding  body,  which  appeared  very  unlike  bone  ;  and 
:he  found  not  a  little  difficulty  in  effecting  the  division  from  the  re- 
ceding of  this  hard  body,  which  he  had  hitherto  considered  as  de- 
tached bone.  When  the  division  was  completed,  he  perceived  a 
round  black  body,  which  he  immediately  recognized  as  the  breech 
of  the  gun.  It  was  laid  hold  of,  first  with  a  pair  of  forceps,  and 
then  with  the  fingers,  and  after  some  difficulty,  extracted.  It  was 
three  inches  or  more  in  length,  and  weighed  three  ounces  and  one 
irachm.  It  had  lain  in  the  brain,  with  one  end  pointing  to  the 
Dccipital,  and  the  other  to  the  frontal  bone  ;  and  consequently  must 
have  extended  nearly  to  the  centre  of  the  brain.  The  patient  im- 
mediately became  paralytic,  and  on  the  3d  day  after  the  extraction, 
died,  under  a  complete  subsultus  tendinum.  Mr.  W.  could  not 
obtain  leave  to  examine  the  head  after  death.* 

7.  Palatial  loss  of  the  substance  of  the  brain,  in  gunshot 
wounds  of  the  orbit.  In  some  cases  of  gunshot  wound  of  the 
orbit,  recovery  has  taken  place  after  partial  loss  of  substance  of  the 
brain. 

The  following  is  an  interesting  case  of  this  sort,  in  several  respects 
resembUng  Mr.  Cagua's  case  of  fractured  orbit,  already  referred  to.t 
A  young  man,  of  17  years  of  age,  was  wounded  by  a  musket  ball, 
which  passing  from  below  upwards,  penetrated  through  the  upper 
lip,  the  right  nostril,  and  the  roof  of  the  orbit  into  the  cranium, 
whence  it  escaped  at  the  upper  part  of  the  frontal  bone  near  to  the 

*  Memoirs  of  the  Medical  Society  of  London  ;  "Vol.  v.  p.  407;     London,  1799. 
^    t  See  page  5. 


24 

sagittal  suture,  where  it  made  a  large  wound  of  the  integumen|i 
with  loss  of  substance.  Such  a  degree  of  swelling  came  on  as  madi 
the  head  frightful.  An  incision  was  made  over  the  wounded  part 
of  the  orbit,  whence  at  the  first  dressing  there  came  out  a  portion 
of  both  substances  of  the  brain,  in  bulk  about  the  size  of  a  small 
hen's-egg.  The  eye  was  exceedingly  swollen,  especially  the  upper 
eyelid,  into  which  an  incision  was  made,  to  give  issue  to  the  blood 
which  was  supposed  to  be  there  extra vasated  ;  but  instead  of  blood, 
there  came  out  a  spUnter  of  bone  and  a  portion  of  both  substances 
of  the  brain,  nearly  equal  to  a  third  of  the  portion  which  had 
formerly  come  away.  The  wounds  were  dressed  lightly,  and  the 
patient  was  repeatedly  bled.  Some  sixiall  portion  of  brain  was 
again  discharged.  On  the  fourth  day,  the  brain  appeared  to  be  in 
a  state  of  suppuration  ;  and  on  the  fifth,  the  discharge  became  very 
considerable.  From  the  time  that  he  had  been  bled,  the  patient 
had  continued  pretty  well  till  the  eleventh  day.  Next  day,  he  was 
more  feeble.  On  the  13th  day,  the  matter  from  the  brain,  which 
had  been  discharged  both  from  the  wound  above  and  from  that 
below,  was  in  part  retained,  and  the  patient  fell  into  a  state  of 
drowsiness  and  general  depression.  M.  Bagieu,  who  treated  the 
case,  having  anevv  examined  the  wounds  witii  minute  attention, 
removed  a  large  piece  of  loose  bone  from  the  upper  part  of  the  skull. 
The  patient  did  not  appear  to  be  reheved  by  this,  but  became  worse 
till  the  15th  day,  when  every  one  expected  him  to  die.  M.  B. 
remarked,  that,  on  pressing  the  skin  where  he  had  removed  the 
piece  of  bone,  pus  oozed  out,  which  made  him  suspect  that  there 
was  an  accumulation  of  matter  at  that  place.  Led  by  this  idea, 
he  removed  the  skin  and  some  portions  of  dura  mater,  so  as  freely 
to  re-estabhsh  the  discharge.  The  pulse  rose,  the  patient  was  next 
day  able  to  speak,  and  afterwards  the  suppuration  slowly  subsided. 
About  the  19th  day,  the  fleshy  parts  began  to  granulate,  and  the 
wound  on  the  upper  part  of  the  head  was  soon  covered  over.  It 
was  otherwise  ^vith  that  of  the  eyelid  :  for  there  supervened  a  con- 
siderable fungus,  occasioned  by  the  splinters  separating  from  the 
neighboring  bone.  In  spite  of  cutting  and  burning  this  fungus,  it 
was  found  necessary  to  wait  patientl}^  till  all  tiiese  splinters  had 
come  away ;  after  which  the  excrescence  was  easily  destroyed,  the 
wound  closed,  and  the  patient  recovered  completely.* 

8.  Part  of  the  orbit  shot  away.  The  temporal  angle  of  the 
orbit  is  peculiariv  exposed  to  this  accident.  Occasionally  a  consid- 
erable portion  of  the  face,  along  with  the  floor  of  the  orbit,  is 
removed ;  and  yet  recovery  may  follow. 

Larrey  relates  the  case  of  a  soldier,  who  was  struck  on  the  face 
with  a  cannon-ball,  which  took  away  almost  the  whole  of  the 
lower  jaw  and  three-fourths  of  the  upper:  the  two  upper  maxillary 
bones,  the  bones  of  the  nose,  the  ethmoid  bone,  and  the  right  malar 

*  Memoires  de  r  Academie  de  Cbirurgie;    Tome  i.  Partie  ii.  p.  127.  12mo.     Paris, 
1780. 


bone,  and  zygoma,  were  broken  to  pieces ;  the  soft  parts  corres- 
ponding to  those  osseous  portions,  destroyed  ;  the  right  eye  burst ; 
the  tongue  cut  across ;  the  fauces,  and  posterior  apertures  of  the 
nostrils  completely  exposed,  as  well  as  one  of  the  glenoid  cavities  of 
the  temporal  bone,  and  the  muscles  and  vessels  of  the  neck.  Such 
was  the  state  of  the  wound,  that  the  comrades  of  this  soldier  had 
laid  him  into  a  corner  of  one  of  the  French  hospitals  at  Alexandria, 
in  the  belief  that  he  was  dead.  Indeed,  when  Larrey  first  saw 
him,  the  pulse  was  scarcely  to  be  felt,  and  the  body  cold  and  with- 
out the  appearance  of  motion.  As  he  had  taken  nothing  for  two 
days,  Larrey's  first  care  was  to  administer  to  him,  by  means  of  an 
oesophagus  tube,  some  soup  and  a  little  wine.  His  strength  was 
re-animated ;  he  raised  himself,  and  testified  by  signs  the  most 
lively  gratitude.  Larrey  washed  the  wound,  removed  the  foreign 
substances  which  adhered  to  it,  cut  away  the  soft  parts  which  were 
in  a  state  of  disorganization,  tied  several  vessels  which  he  had 
opened  in  doing  so,  and  brought  the  flaps  together  as  much  as  pos- 
sible by  stitches.  He  also  united  by  stitches  the  two  portions  into 
which  the  tongue  had  been  divided.  He  covered  the  whole  exca- 
vation with  a  holed  cloth  dipped  in  warm  wine,  and  then  applied 
fine  charpie,  compresses,  and  a  bandage.  Every  3  hours,  a  little 
soup  and  some  spoonfuls  of  wine  were  given  with  the  gum-elastic 
tube  and  funnel.  The  dressings  were  frequently  renewed,  on 
account  of  the  flow  of  saliva,  and  other  fluids.  Suppuration  was 
estabUshed,  the  sloughs  separated,  the  edges  of  the  enormous  wound 
approached  one  another,  the  parts  which  were  brought  together 
adhered ;  35  days  after  the  injury  the  man  was  in  a  state  to  be 
moved,  and  ultimately  cicatrization  was  completed.  After  having 
been  supported  during  the  first  15  days  by  means  of  the  tube,  he 
Vfas  able  to  take  food  v/ith  a  spoon.  He  retm-ned  to  France,  and 
11  years  afterwards,  when  Larrey  published  his  work,  was  alive, 
and  in  good  health,  in  the  Hotel  des  Invalides.  He  could  even 
speak  so  as  to  make  him^self  understood,  especially  when  the  large 
opening  into  his  face  was  covered  with  a  silver  mask." 

I  have  thus  attempted  to  classify  and  illustrate  the  various  In- 
juries to  which  the  orbit  is  hable,  and  the  various  effects  which 
those  Injuries  are  apt  to  produce. 

There  remain  only  two  topics,  on  .which  I  wish  to  say  a  few 
words. 

1.  Prognosis.  It  is  evident  from  the  cases  which  have  passed 
in  review  before  us,  that  although  in  general,  immediate  death  is 
the  consequence  of  an  injury  extending  through  the  orbit  to  the 
brain,  yet  this  is  not  always  the  case  ;  but  that  in  some  cases  life 
has  been  prolonged  for  several  days,  and  that  in  other  cases  the 
patient  has  completely  recovered. 

It  is  probable,  that  it  is  not  so  much  the  absolute  amount  of  in- 

*  Larrey,  Memoires  de  Chirurgie  Militaire ;  Tome  ii.  p.  140.     Paris,  1812. 


26 

jury  to  the  brain,  as  the  suddenness  with  which  it  is  inflicted,  which 
renders  wounds  of  the  brain  through  the  orbit  so  generally  fatal. 
We  have  examples  of  disorganization  of  very  considerable  portions 
of  the  brain  proceeding  slowly,  for  years,  and  yet  life  prolonged ; 
while  in  perforation  of  the  roof  of  the  orbit,  the  smallest  wound  oif , 
the  brain  may  prove  immediately  mortal.  Pathologists  have  gene- 
rally attempted  to  explain  the  sudden  and  fatal  effects  of  such  ; 
wounds  of  the  brain,  by  telling  us.  that  thereby  the  heart,  or 
the  organs  of  respiration,  are  instantly  deprived  of  the  nervous 
energy  necessary  for  continuing  their  functions,*  But  how  it  hap- 
pens that  death  takes  place  instantaneously  in  some  cases  of  this 
sort,  while  others  sufier  so  little  from  sudden  injury  of  the  brain, 
but  linger,  like  Mr.  Waldon's  patient  with  the  gun-breech  in  his 
brain,  or  recover  like  Mr,  Cagua's  and  M.  Bagieu's  patients,  we 
cannot  tell,  any  more  than  we  can  explain  how  one  man  shall 
have  a  limb  carried  off,  or  shattered  to  pieces,  by  a  cannon-ball, 
without  exhibiting  the  slightest  symptom  of  mental  or  corporeal 
agitation,  while  deadly  paleness,  violent  vomiting,  profuse  perspira- 
tion, and  universal  tremor,  will  seize  another  on  the  receipt  of  a 
slight  flesh  wound.  To  say  that  all  this  depends  on  differences  in 
nervous  susceptibility,  is  only  to  repeat  the  fact  in  other  words,  not 
to  explain  it. 

2.  General  Treatment.  In  regard  to  the  general  treatment 
of  Injuries  of  the  Orbit,  it  is  very  plain  what  that  ought  to  be ; 
namely,  quiet  and  rest ;  a  very  spare  diet ;  blood-letting,  if  the  re- 
action demands  it ;  opiates ;  laxatives ;  gentle  diaphoretics  ;  a  little 
blue  pill  occasionally,  if  the  liver  becomes  irregular  in  its  action,  as 
from  confinement  it  is  very  apt  to  do ;  great  cleanliness  in  regard  to 
the  injured  parts ;  emollient  cataplasms,  and  soft  light  dressings, 
frequently  renewed. 

We  must  beware  of  neglecting  the  use  of  blood-letting,  and  we 
must  beware  of  employing  this  remedy  too  soon  and  too  profusely. 
We  must  not  omit  to  examine  the  injured  parts  frequently,  in  order, 
if  there  be  any  piece  of  exfoliated  bone  or  foreign  substance  keeping 
up  irritation,  that  it  may  be  withdrawn ;  and,  on  the  other  hand, 
we  must  beware  of  too  much  poking  and  intermeddling,  and  of 
attempting  prematurely  to  close  up  the  issues,  by  which  matter 
and  foreign  substances  may  have  still  to  escape. 


SECTION    II. PERIOSTITIS,     OSTITIS,     CARIES,    AND    NECROSIS 

OF    THE    ORBIT. 

We  have  hitherto  considered  the  orbit  merely  as  a  part  exposed 
to  a  variety  of  external  injuries.  We  must  now  ture  our  attention 
to  it  as  a  part  subject  to  inflammation  and  its  consequences. 

*  Les  playes  du  cerveau  et  des  membranes  sont  mortelles  le  plus  souvent,  a  cause 
que  souventesfois  s'en  ensuit  ablation  de  Paction  des  muscles  du  thorax,  et  des  autres 
servants  a  la  respiration :  dont  de  necessite  la  mort  s'ensuit.    Pare,  Liv.  x.  Chap.  10. 


27 

It  is  generally  admitted  that  the  bones  are  susceptible  of  the 
ame  diseases,  as  the  soft  parts ;  only,  on  account  of  the  mineral 
'natter  which  they  contain  in  the  proportion  of  about  2  to  1  of 
mimal  matter,  the  whole  of  the  processes,  whether  natural  or 
norbid,  which  go  on  in  the  bones,  take  place  with  much  less 
apidity,  and  with  much  fewer  manifestations  of  vitality,  than  do 
imilar  processes  in  the  soft  parts.  Inflammation  in  particular, 
ilceration,  and  mortification,  with  all  their  concomitant  phenomena, 
(roceed  in  general  very  slowly  in  bones.  The  periosteum,  with 
Ivhich  they  are  every  where  invested,  possesses  a  much  greater 
legree  of  vitality ;  and  as  this  membrane  is  not  merely  firmly  ad- 
;  lerent  to  their  surfaces,  but  sends  innumerable  vessels  into  their 
:ubstance,  we  find  the  bones  very  much  aflfected  in  every  case  in 
vhich  the  periosteum  is  diseased. 

It  is  an  old  and  a  just  notion,  that  the  dura  mater,  making  its 
ixit  by  the  numerous  foramina  of  the  cranium,  is  continued  into 
he  periosteum.  The  dura-matral  envelope  for  the  optic  nerve, 
[laving  reached  the  point  of  origin  of  the  recti  muscles  of  the  eye, 
j  splits  into  two  laminae,  the  external  of  which  is  lost  in  the  perios- 
i.eum  of  the  orbit,  while  the  internal,  which  is  whiter,  denser, 
i  md  thicker,  goes  on  closely  to  surround  the  nerve,  and  ultimately 
I  )ecomes  continuous  with  the  sclerotica.  Between  these  two  laminae, 
1  canal  is  formed  for  the  transmission  of  the  ophthalmic  artery, 
[t  is  not  by  the  optic  foramen  alone  that  the  dura  mater  enters  the 
Drbit.  The  dura  mater  closes  in  part  the  spheno-orbital  fissure,  and 
sends  into  the  orbit  by  this  opening  a  prolongation,  which  is  also  con- 
cinued  into  the  periosteum  of  the  orbit.  This  prolongation,  allows 
the  3d,  4th,  1st  division  of  the  5th,  and  6th  nerves  to  enter  the 
3rbit,  and  the  ophthalmic  vein  to  escape  from  it. 

Causes.  Inflammation  of  the  bones  and  periosteum  (ostitis  and 
periostitis  of  the  orbit  may  be  the  result  of  several  different  kinds 
of  causes ;  for  example,  1st,  Syphilis,  scrofula,  and  other  internal 
diseases,  of  a  constitutional  nature,  acting  locally ;  2d,  Injuries, 
perhaps  attended  with  fracture ;  and  3d,  The  spread  of  inflamma- 
tion from  the  neighbouring  parts,  and  especially  from  the  soft  parts 
contained  within  the  orbit.  We  should  call  the  first  two  examples 
-primary,  and  the  last  secondary  inflammation  of  the  orbit.  This 
last  is  by  far  the  most  common. 

Inflammation  of  the  bones  of  the  orbit,  primarily  or  secondarily- 
excited,  may  terminate  by  resolution,  merely  an  increased  deposi- 
tion of  osseous  matter  being  left  in  the  inflamed  part,  hyperostosis ;* 
it  may  terminate  in  the  formation  of  pus,  and  ulcerative  absorption 
of  the  substance  of  the  bone,  caries  ;  or  in  the  death  of  the  inflamed 
piece  of  bone,  necrosis,  t 


*  I  shall  have  occ*ion  to  quote  an  interesting  case  of  hyperostosis  of  the  orbit,  in 
the  next  section. 

t  See  Dr.  Cumin's  Paper  on  the  Diseases  of  Bones,  in  the  Edinburgh  Medical  and 
Surgical  Journal,  Vol.  xxiii. 


28  . 

It  will  rarely  be  possible  to  decide  at  first  sight,  in  cases  of  dis- 
eased orbit,  whether  the  bone  which  is  felt  bare  with  the  probe,  is 
carious  or  necrosed,  or  whether  both  caries  and  necrosis  are  present. 
The  exact  nature  of  the  disease  will  become  evident  only  in  the 
course  of  the  cure,  from  the  sensations  communicated  through  the 
medium  of  the  probe,  the  foetor  emitted,  the  appearances  of  the 
discharge,  and  the  texture  and  size  of  the  pieces  of  bone  which 
come  away. 

I  do  not  consider  it  necessary  to  describe,  farther  than  I  have 
done,  the  inflammatory  effects  of  injuries  of  the  orbit.  In  pene- 
trating wounds  especially,  and  in  gunshot  wounds  of  the  orbit,  w^e 
must  lay  our  account  with  inflammation  of  the  bones  and  perios- 
teum, followed  by  suppurations,  sloughings,  sinuses,  caries,  necrosis, 
and  tedious  exfoliations. 

Demours  speaks  of  primary  inflammation  of  the  orbital  perioste- 
um as  extremely  common  *  ;  but  the  symptom  to  which  he  refers, 
is  evidently  nothing  more  than  the  supj'a-orbitalpain,  which  return- 
ing every  evening  and  relaxing  every  morning,  is  an  invariable 
attendant  on  rheumatic  ophthalmia. 

The  most  frequent  cause  of  secondary  inflammation  of  the  bones 
of  the  orbit,  is  inflammation  of  the  orbital  cellular  substance,  or  of 
the  lachrymal  gland,  going  on  to  suppuration,  and  the  abscess  from 
misapprehension  or  neglect  not  evacuated  ;  while  in  some  cases,  se- 
vere inflammation  of  the  eyeball  spreads  not  only  to  the  surround- 
ing soft  parts,  but  also  to  the  periosteum  and  the  bones. 

Inflammation  of  the  orbital  cellular  substance,  going  on  to  sup- 
puration, may  take  place  near  the  front  of  the  orbit,  between  the 
levator  palpebree  superioris  and  the  orbit,  between  that  muscle  and 
the  rectus  superior  oculi,  or  below  the  eyeball,  between  the  rectus 
inferior  oculi  and  the  floor  of  the  orbit.  Inflammation  and  suppu- 
ration in  these  situations  are  attended  with  pain  and  fever,  immo- 
bihty  and  distortion  of  the  eyeball,  and  much  swelling  of  the  eye- 
lids. If  the  disease  be  understood  from  the  first,  and  treated  on  an 
active  antiphlogistic  plan,  suppuration  may  often  be  prevented  :  if 
matter  has  actually  formed,  any  very  serious  or  extensive  injury 
may  still  be  obviated  by  opening  the  abscess  sufficiently  early  ;  but 
neglected  or  misundei-stood,  an  abscess  even  near  the  front  of  the 
orbit,  perhaps  pointing  and  fluctuating  through  one  or  other  eyelid, 
may  spread  its  mischief  to  the  periosteum  and  bones,  or  insinuate 
itself  into  some  of  the  neighboring  cavities,  into  the  nostril  by  the 
lachrymal  passage,  into  the  zygomatic  fossa  by  the  spheno-maxil- 
lary  fissure,  into  the  maxillary  smus  through  the  floor  of  the  orbit, 
or  even  into  the  cavity  of  the  cranium  through  the  orbitary  plate 
of  the  frontal  bone.  It  will  penetrate  through  the  bones  in  the  last 
two  cases,  by  the  process  of  progressive  absorption,  a  process  attend- 
ed by  inflammation  in  the  bones  pressed  upon,  aftd  leaving  these 

•  Traite  des  Maladies  des  Yeux.     Tome  i,  p.  91.    Paris,  1818. 


29 

)ones  in  a  diseased  state,  but  seldom,  if  ever,  in  the  state  either  of 
;aries  or  necrosis.  It  is  where  there  is  no  perforation  from  the  orbit 
nto  the  neighbouring  cavities,  but  merely  a  sjDreading  of  inflamma- 
ion  to  the  periosteum  and  bones,  that  caries  or  necrosis  is  most  apt. 

0  take  place. 

Of  a  still  more  dangerous  character  is  inflammation  in  the  back 
jart  of  the  orbit,  or  in  the  cellular  membrane  immediately  surround- 
ng  the  optic  nerve.  Vision  is  always  more  or  less  injured,  and 
)ften  destroyed  by  suppuration  in  these  situations  ;  the  eyeball  i& 
)ushed  more  or  less  forwards  from  its  natural  situation  ;  not  unfre- 
juently  exophthalmia  follows  hard  upon  this  state  of  exophthalmosy 
,hat  is  to  say,  the  eyeball  is  destroyed  by  inflammatory  disorgani- 
sation as  well  as  protruded  ;  nay,  I  have  known  deep-seated  abscess 
)f  the  orbit  to  prove  fatal,  the  patient  having  for  a  day  or  two  shown 
symptons  of  pressure  on  the  brain,  and  in   fact  dying  apoplectic. 

1  need  scarcely  say  that  in  such  cases,  the  periosteum  and  bones  of 
the  orbit  will  be  very  apt  to  suffer,  especially  if  the  disease  is  pro- 
longed, and  no  attempt  made  to  evacuate  the  abscess  which  may 
have  formed. 

I  do  not  consider  it  necessary  to  describe  these  diseases  of  the 
orbital  cellular  membrane  njore  minutely  for  the  present.  Them, 
as  well  as  inflammation  of  the  eyeball  spreading  to  the  cellular 
membrane,  periosteum,  and  bones  of  the  orbit,  and  inflammation 
of  the  lachrj'mal  gland  running  the  same  course,  I  shall  take  up 
separately  hereafter.  I  mention  them  now,  merely  as  the  most 
common  causes  of  caries  and  necrosis  of  the  bones  of  the  orbit. 

When  the  bones  of  the  orbit  inflame  from  syphilis,  after  pain  io 
the  seat  of  the  disease,  not  in  general  acute,  there  forms  a  tumour 
of  the  eyelids,  shghtly  red  at  first,  and  but  little  painful  to  the 
touch,  but  which  slowly  advances  in  redness,  pain,  and  size,  till  it  is 
felt  to  fluctuate,  and  either  bursts  of  itself  or  is  opened  with  the 
lancet.  It  is  but  rarely  that  we  have  an  opportunity  of  watching 
the  invasion  and  progress  of  such  a  case.  Much  more  frequently 
the  patient  applies  for  aid,  only  after  the  abscess  has  biu'st  and 
discharged  matter  for  a  length  of  time. 

Local  Sym'ptoms.  Let  caries  or  necrosis  of  the  orbit  have  arisen 
from  whatever  cause  it  may,  let  it  be  primary  or  secondary,  the  re- 
sult of  some  constitutional  disorder,  as  syphilis,  or  of  an  injury,  as 
many  of  those  injuries  we  have  already  described,  or  of  inflamma- 
tion spreading  from  the  contents  of  the  orbit,  the  following  are 
some  of  the  appearances  which  may  lead  us  to  suspect  the  exis- 
tence of  such  an  affection  : — A  fistulous  opening  through  one  or 
other  eyelid,  more  frequently  through  the  upper,  sometimes  just  un- 
der the  center  of  the  superciliary  arch,  but  generally  nearer  to  the 
outer  extremity  of  this  arch ;  the  opening  of  the  fistula  callous,  or 
perhaps  fungous  ;  the  skin  around  red,  hard,  depressed,  and  drawn 
back  into  the  orbit ;  the  eyelid  shortened,  so  that  the  eyeball  cannot 
be  completely  covered  by  the  lids  when  the  patient  attempts  to  close 


30 

them,  a  symptom  called  lagophthalmos  ;  eversion  of  the  lid  through 

which  the  fistula  passes,  sometimes  to  a  very  great  degree ;  a  dis- 
charge of  ichorous  matter  from  the  fistula,  the  quantity  discharged 
being  too  great  in  general  to  be  furnished  by  the  small  opening 
which  is  visible.  These  appearances,  we  learn  from  the  patient, 
have  been  consequent  to  symptoms  of  inflammation  of  the  orbit,  with 
or  without  injury,  ending  in  abscess,  which  had  either  been  opened 
with  the  lancet,  or  allowed  to  burst  of  itself.  If  we  take  the  probe, 
and  pass  it  along  such  a  fistula,  it  generally  comes  into  contact  with 
bare,  rough  bone.  I  believe  it  will  rarely  be  the  case,  that  the 
bone,  under  such  circumstances,  has  been  merely  exposed,  by  the 
formation  of  an  abscess  in  its  neighbourhood,  and  by  the  evacuation 
of  that  abscess  :  but  that,  on  the  contrary,  the  bone  is,  in  general. 
affected,  either  with  necrosis,  in  which  case  a  cure  is  likely  to  be 
sooner  effected,  or  with  caries,  and  then  the  cure  is  generally  very 
slow. 

It  sometimes  happens  that  several  different  portions  of  the  orbit 
are  affected  at  the  same  time,  ending  in  the  formation  of  a  number 
of  sinuses,  passing  through  the  eyelids  in  the  direction  of  the  dis- 
eased pieces  of  bone.  Such  a  state  is  commonly  the  result  of  se- 
vere and  general  inflammation  of  the  orbital  cellular  membrane, 
running  on  into  suppuration.  When  the  floor  or  the  inner  wall 
of  the  orbit  is  the  seat  of  caries  or  necrosis,  excited  in  this  way,  we 
almost  alwa^'S  find  that  the  whole  thickness  of  the  bones  has  in  a 
greater  or  less  extent  been  destroyed,  permitting  the  matter  to  drain 
from  the  orbit  into  the  nostiil  or  into  the  maxillary  sinus.  A  case 
of  this  kind  is  related,  ia  a  desultory  aud  tedious  manner,  by  De- 
mours.  The  patient  was  a  canon  of  Besancon,  in  whom  it  would 
appear  that  suppuration  had  entirely  destroyed  the  cellular  mem- 
brane of  the  orbit,  and  that  a  part  of  the  upper  lid  had  been  lost  by 
gangrene.  The  eyeball  was  destroyed,  the  upper  lid  was  left  evert- 
ed and  shortened,  and  four  fistulous  openings  existed  into  the  orbit, 
two  at  the  inner  and  two  at  the  upper  edge.  FcEtid  matter,  mixed 
w"ith  curdlike  substance,  was  discharged,  some  pieces  of  bone  came 
away,  injections  passed  for  a  time  from  the  orbit  into  the  maxillary 
sinus  and  nostrils,  at  last  the  discharge  ceased,  the  parts  became  quiet, 
the  sinuses  closed,  and  a  glass  eye  was  applied  to  cover  as  much  as 
possible  the  deformity.  The  general  health  does  not  appear  to 
have  been  affected.  The  chief  local  treatment  consisted  in  mild 
injections,  frequently  repeated  in  the  course  of  the  day.* 

Saint-Yves  mentions  his  having  treated  a  lad  of  15  years  of  age, 
who  had  had  an  abscess  under  the  eyeball,  which  had  burst  through 
the  middle  of  lower  eyehd.  On  passing  a  probe  through  the  open- 
ing, he  found  that  the  matter,  lodging  under  the  globe  of  the  eye, 
had  produced  caries  of  the  floor  of  the  orbit.  The  matter  had  flowed 
into  the  maxillary  sinus,  and  was  discharged  in  part  by  the  nostril. 

♦  Demouis,  Traite  des  Maladies  des  Yeux.    Tome  ii.  p.  33,  Paris,  1818. 


31 

Fearing  that  the  presence  of  pus  in  the  maxillary  sinus  might  bring 
Dn  caries  of  that  cavity,  Saint- Yves  extracted  one  of  the  molares, 
the  root  of  which  he  thought  likely  to  penetrate  into  the  sinus,  and 
then  employed  injections,  morning  and  evening,  through  the  open- 
ing in  the  eyelid.  The  fluid  injected  ran  through  the  maxillary 
5inus,  and  through  the  alveolus,  into  the  mouth.  The  injection 
employed  was  a  decoction  of  aristolochia,  gentian,  and  myrrh.  In 
two  months  the  patient  was  cured.* 

Although  caries  of  the  orbit  is  generally  attended  by  abscess  of 
the  soft  parts  in  its  neighbourhood,  (if  it  has  not  originated  itself  in 
such  abscess,)  the  skin  of  one  or  other  eyelid  inflaming,  and  at 
length  giving  way,  and  an  external  flstula  forming,  yet  cases  may 
Dccur  in  which  the  disease  shall  be  situated  very  deep  in  the  orbit, 
in  the  sphenoid  bone,  for  example,  where  it  gives  passage  to  the 
optic,  or  other  orbital  nerves,  so  that  amaurosis  may  be  brought  on, 
any  suppuration  of  the  soft  parts  w4iich  may  form  shall  lie  long 
concealed,  or  even  death  be  the  result  before  any,  or  almost  any 
external  marks  of  the  disease  be  present. 

/State  of  the  Constitution.  We  ought  not  to  proceed  to  the 
treatment  of  any  case  of  diseased  bones  of  the  orbit,  till  we  have 
made  ourselves  acquainted  with  the  state  of  the  patient's  general 
health,  and  as  much  as  possible  with  the  history  of  the  local  dis- 
ease. 

Children  are  not  unfrequently  the  subjects  of  diseased  bones  of 
the  orbit;  strumous  children,  who  have  suffered  inflammation  of  the 
lachrymal  gland,  and  in  whom  the  fossa  lachryraalis  of  the  frontal 
bone  has  become  carious. 

In  other  cases,  the  subject  is  adult  and  syphilitic.  I  have  seen 
both  orbits  affected  in  such  an  individual. 

T  have  seen  caries  of  the  roof  of  the  orbit,  in  an  elderly  man,  free 
from  any  venereal  disease,  and  who  could  give  no  accoimt  of  the 
origin  of  his  complaint. 

It  is  evidently  impossible  to  decide  from  a  mere  examination  of 
the  diseased  bone,  what  has  been  the  nature  of  the  inflammation 
in  which  the  caries  or  necrosis  has  originated,  whether  syphilitic, 
or  strumous,  or  scorbutic,  or  of  what  other  kind.  We  must  refer  to 
the  history  of  the  case  and  the  constitutional  symptoms,  in  order  to 
deteimine,  if  possible,  this  point. 

In  syphilitic  cases,  we  might  be  led  to  expect  considerable  pain, 
aggravated  during  the  night ;  although  nothing  of  this  kind  ex- 
isted in  the  only  case  of  syphilitic  caries  of  the  orbit  which  I  have 
seen.  Other  bones,  besides  those  of  the  orbit,  are  likely  in  such 
cases  to  be  affected  with  similar  disease.  The  bones  of  the  nose, 
and  the  frontal  bone  where  it  forms  the  forehead,  are  much  more 
apt  to  be  affected  with  syphilitic  inflammation,  than  are  the  walls 
of  the  orbit.     Mr.  Hawkins,  in  a  paper  on  Syphihtic  Pains  and 

*  Saint- Yves,  Nouveau  Traite  des  Maladies  des  Yeux,  p.  80.     Paris,  1722 


32 

Diseases  of  the  Bones,*  refers  to  a  case  iii  which  the  orbits  appear 
to  have  been  the  last  parts  afiected.  He  speaks  of  it  as  the  most 
frightful  example  of  syphilitic  disease  of  the  bone  wihch  he  had  wit- 
nessed. The  skull  is  preserved  in  the  museum  of  the  London 
Royal  College  of  Surgeons,  along  with  a  pi'eparation  of  the  scalp, 
showing  the  great  extent  to  which  it  also  had  been  destroyed  by 
ulceration.  The  disease  of  the  bones  reached  (says  Mr.  H.)  into 
the  orbits,  so  as  to  produce  complete  and  disgusting  eversion  of  the 
eyelids,  terminating  in  total  blindness.  The  brain  was  little  dis- 
turbed by  the  great  extent  of  the  disease,  till  the  last  two  months  of 
the  patient's  life,  when  frequent  convulsions  took  place,  with  gradual 
loss  of  the  mental  faculties. 

In  the  case  to  which  I  have  referred,  in  which  both  orbits  were 
affected,  it  appeared  that  the  patient  had  had  a  similar  disease  of 
the  right  acromion,  a  painful  node  on  the  left  side  of  the  forehead, 
and  repeated  chancres  and  buboes,  during  the  18  months  preceding 
the  disease  of  the  orbits.  Such  a  history  naturally  led  to  the 
conclusion  that  the  disease  of  the  orbits  was  syphilitic. 

Prognosis.  It  is  evident  that  both  the  prognosis  and  the  treat- 
ment will  be  different  in  different  cases.  In  a  healthy  adult,  in 
whom  the  affection  of  the  bones  is  the  result  of  an  injury,  the 
prognosis  will  be  much  more  favourable,  and  the  treatment  more 
simple,  than  in  a  strumous  child,  or  an  individual  whose  constitu- 
tion is  either  imbued  with  the  poison  of  syphilis  or  impaired  by 
frequent  courses  of  mercury. 

In  respect  to  the  prognosis,  I  may  mention  that  the  eye  is  in 
danger  of  being  destroyed  in  cases  of  caries  of  the  orbit,  simply  in 
consequence  of  the  lagophthalmos,  or  incapabihty  from  shortening 
of  the  eyelid  of  closing  the  eye.  In  every  case  of  caries  of  the 
orbit  which  I  have  seen,  there  was  either  eversion,  or  lagophthal- 
mos, or  both,  and  in  consequence  of  the  eyeball  being  but  partially 
covered  when  the  patients  attempted  to  shut  the  eyes,  there  was 
always  inflammation  of  the  conjunctiva,  sometimes  inflammation 
and  nebula  of  the  cornea ;  and  in  one  case  in  which  the  lagoph- 
thalmos was  to  a  great  extent,  the  upper  eyelid  being  permanently 
drawn  by  the  sinus  upwards  and  backw^ards  into  the  orbit,  so  that 
a  ver\^  considerable  portion  of  the  eyeball  was  continually  exposed 
to  the  contact  of  the  air  and  of  foreign  particles  floating  through  it, 
there  were  pustule  of  the  cornea  and  onyx.  I  was  consulted  only 
once  in  this  case,  but  I  had  no  doubt  that  the  cornea  would  soon 
after  be  so  much  affected  as  to  give  way,  and  the  eye  be  ultimate- 
ly left  staphylomatous  or  atropiiic.  The  caries  affected  the  roof  of 
the  orbit,  immediately  behind  the  middle  of  the  supra-orbilary 
arch. 

Local  Treatment.  In  the  local  treatment,  our  object  is,  if  the 
disease  be  caries,  to  arrest  the  ulcerative  process  going  on  in  the 

*  London  Medical  and  Physical  Journal.    Vol.  Ivii.  p.  318.   Lond.   1827. 


33 

bone ;  if  necrosis,  to  promote  the  exfoliation  of  the  portion  which  is 
deprived  of  life. 

i  We  shall  rarely  be  able  to  accomplish  either  of  these,  without  di- 
llating'  the  fistulee  which  communicate  with  the  diseased  bone. 
!  This  is  to  be  done  partly  with  the  knife,  partly  with  tents.  The 
j  opening  of  the  fistula  may  first  of  all  be  enlarged,  by  means  of  a 
straight,  narrow,  probe-pointed  bistoury.  This  instrument  may 
then  be  introduced  along  the  fistula,  and  directing  its  edge  first 
[upwards  and  then  downwards,  it  is  to  be  pretty  freely  dilated.  To 
■  keep  it  open,'  a  dossil  of  lint,  dipped  in  almond  oil,  is  to  be  pushed 
i  along  until  it  comes  into  contact  with  the  diseased  bone. 
I  In  cases  of  children,  or  of  adults  who  are  afraid  of  the  knife,  we 
imay  be  induced  to  dilate  the  fistula  by  sponge-tent,  although  this 
s  in  fact  the  more  painful  method  of  the  two  ;  so  painful  indeed 
;chat  it  sometimes  cannot  be  borne.  If  there  are  fungous  granula- 
tions round  the  opening  of  the  fistula,  these  first  of  all  may  be  de- 
stroyed with  lunar  caustic.  If  there  be  no  fungus,  the  pointed 
pencil  of  lunar  caustic  may  at  once  be  introduced  into  the  fistula, 
and  turned  round  two  or  three  times,  so  as  to  enlarge  it.  A  pencil 
of  sponge-tent  is  then  to  be  introduced,  and  kept  in  for  ten  or  twelve 
hours.  Thicker  and  thicker  pieces  of  sponge-tent  are  then  to  be 
[employed,  till  the  opening  becomes  large  enough  to  admit  a  dossil 
of  lint,  dipped  in  oil  or  covered  with  digestive  ointment,  and  pushed 
an  into  contact  with  the  diseased  bone. 

Various  applications  have  been  recommended  in  cases  of  caries 
and  necrosis  ;  but  perhaps  nothing  is  deserving  of  so  much  confi- 
dence as  lunar  caustic, ^either  solid  or  in  solution.  Every  second  or 
third  day,  a  strong  solution  of  this  substance  may  be  injected  along 
the  fistula,  taking  precautions  against  the  solution  being  allowed  to 
touch  the  eye  ;  or  the  caustic  pencil  may  be  conveyed  into  contact 
with  the  bone,  and  kept  there  for  the  space  of  about  half  a  mirnite. 

In  general,  no  cure  takes  place  in  such  cases  unless  the  diseased 
bone  comes  away  ;  but  the  coming  away  of  the  bone  is  not  always 
svident.  It  sometimes  separates  in  minute  scales,  sticking  to  the 
dossil  of  lint,  or  washed  out  by  the  injection ;  while  in  other  cases, 
a  considerable  portion  is  thrown  off  at  once,  is  felt  with  the  probe 
to  be  loose,  and  is  to  be  extracted  with  the  forceps.  There  is  no 
stated  time  for  the  necessary  exfoliation  in  such  cases.  It  may  take 
place  in  a  month  ;  or  many  months  may  elapse  before  the  diseased 
bone  comes  entirely  away.  As  soon  as  we  judge  it  probable  that 
the  whole  diseased  part  has  been  removed,  we  lay  aside  the  dossil 
of  lint,  and  allow  the  opening  to  close. 

I  do  not  imagine  that  in  cases  of  caries  or  necrosis  of  the  bones 
of  the  orbit,"  there  ever  is  any  considerable  formation  of  new  bone. 
All  that  nature  effects  in  such  cases,  is,  I  believe,  a  healing  up  of 
the  diseased  part,  without  any  attempt  to  restore  what  has  been  re- 
moved by  ulcerative  absorption,  or  by  exfoliation.  Fortunate  in- 
deed must  the  case  be  regarded,  when  the  former  process  ceases,  or 

5 


34 

the  latter  is  completed,  so  that  the  diseased  bone  may  heal,  and  the 
external  wound  be  allowed  to  close,  and  this  without  any  consid- 
erable deformity.  The  eversion  of  the  eyelid,  the  impossibility  of 
covering  the  eye,  and  the  deformity  caused  by  the  retraction  of  the 
external  aperture  of  the  fistula,  are  events  very  annoying  under  any 
circumstances.  Suppose  the  patient  to  be  a  young  lady,  naturally 
anxious  about  her  appearance,  I  need  scarcely  say  how  meritorious 
the  surgeon  will  be  in  her  judgment  and  that  of  her  friends,  if  the 
case  is  brought  to  a  speedy  and  favorable  termination,  especially  if 
they  have  ever  witnessed  the  deformity  and  the  destruction  of  the 
eye  which  may  have  been  the  result  in  less  fortunate  cases  of  the 
same  disease. 

It  may  sometimes  happen  that  we  are  deceived  in  regard  to  the 
state  of  the  bone.  The  fistula  may  even  close,  and  yet  the  bone 
continue  diseased.  Granulations  may  fill  up  the  sinus,  without  its 
bottom  being  sound.  Perhaps  some  trifling  exfoliation  has  taken 
place,  without  the  whole  diseased  piece  of  bone  having  come  away  ; 
and  the  surgeon,  misled  by  appearances,  and  thinking  that  all  is 
right,  does  his  best  to  close  up  the  sinus.  Nothing,  however,  is 
gained,  if  the  bone  is  still  left  in  a  state  of  disease.  On  the  con- 
trary, we  are  only  obliged  to  go  over  again  the  same  process  of  di- 
latation, and  to  wait  for  renewed  exfoliation. 

General  Treatment.  The  exfoliation  and  healing  up  of  dis- 
eased bone  is  throughout  an  organic  process,  and  may  unquestion- 
ably be  assisted  by  whatever  remedies  tend  to  support  or  improve 
the  general  health. 

In  syphilitic  cases,  mercury,  sarsapariila,  and  other  anti-venereal 
remedies,  are  to  be  employed.  In  strumous  cases,  sulphate  of  quina, 
other  tonics,  a  nourishing  diet,  and  country  air,  will  be  found  ad- 
vantageous. 

1  have  no  experience  of  the  power  of  asafcetida,  and  a  variety  of 
other  internal  remedies,  which  have  gained  a  reputation  for  pro- 
moting the  exfohation  and  heahng  up  of  bones.  If  they  act  at  all, 
they  probably  do  so  merely  as  stimulants  or  tonics,  without  any  of 
the  specific  power  over  diseased  bone,  which  has  been  attributed  to 
them. 

SequelcB.  Unless  when  the  separation  of  the  diseased  portion  of 
bone  and  the  healing  up  of  the  sinus  have  been  more  than  com- 
monly prompt,  it  is  rarely  the  case,  that  recovery  takes  place  from 
caries  or  necrosis  of  the  orbit,  without  a  considerable  degree  of  la- 
gopthalmos,  or  eversion,  or  both. 

1  am  afraid  that  the  lagopthalrnos  in  such  cases  must  be  regard- 
ed as  incurable ;  or  if  it  be  at  all  relievable.  it  is  so  not  by  art,  but 
by  a  loosening  of  the  retracted  eyelid  effected  slowly  by  the  natural 
action  of  the  orbicularis  palpebrarum.  In  a  patient  who  was  under 
my  care,  at  the  Eye  Infirmary,  with  caries  of  the  roof  of  each  orbit, 
and  lagopthalmos  of  each  upper  eyelid,  the  eyelids  came  very  grad- 
ually to  close  more  and  more  upon  the  eyeballs.     For  a  time,  how- 


3S 

ever,  the  lag-ophthalmos  was  to  such  a  degree  as  to  leave  the  con- 
junctiva constantly  exposed  to  the  irritation  of  the  air  and  the  par- 
ticles of  dust  floating  through  it.  The  conjunctivitis  and  corneitis, 
thereby  excited,  I  treated  chiefly  by  the  apphcation  of  the  lunar 
caustic  solution,  till  the  elongation  of  the  eyelids,  produced  by  the 
action  of  the  orbiculares  palpebrarum  in  winking,  rendered  the  la- 
gophthalmos  gradually  less  and  less,  and  served  at  length  to  permit 
the  eyeballs  to  be  almost  completely  covered.  When  this  patient 
was  dismissed,  the  sinuses  had  long  been  healed.  There  still  re- 
mained a  slight  speck  on  one  of  the  cornese  ;  and  an  evident  de- 
ficiency was  felt  at  the  part  of  each  orbit  which  had  been  the  site 
of  the  caries.  The  lunar  caustic  solution  was  of  signal  service  in 
this  case,  moderating  the  external  inflammation  of  the  eyeballs, 
brought  on  from  their  state  of  exposure,  and  in  fact  saving  the 
eyes,  till  the  natural  apparatus  of  protection  was  in  a  great  measure 
restored  to  the  exercise  of  its  office. 

I  had  another  patient  at  the  Eye  Infirmary,  (a  boy  of  li  years 
of  age),  with  a  great  degree  of  eversion  of  the  right  upper  lid,  at- 
tendant on  caries  of  the  fossa  lachrymalis.  I  used  the  lunar  caus- 
tic injection  in  this  boy,  who  was  of  a  decidedly  strumous  habit, 
and  attempted  dilatation  by  sponge-tents.  This  of  course  was  at- 
tended with  a  considerable  degree  of  pain  ;  and  he  ceased  on  this 
account  to  attend.  I  need  scarcely  say  that  it  would  be  folly  to 
attempt  the  cure  of  the  eversion  in  such  a  case,  if  the  fistula  were 
still  open,  or  the  bone  unsound.  Were  we  to  detach  the  eyelid 
from  the  edge  of  the  orbit  to  which  it  is  drawn  up,  replace  it  in  its 
natural  position,  and  endeavor  to  keep  it  so,  perhaps  by  extirpating 
a  portion  of  the  exposed  and  thickened  conjunctiva,  or  cutting  out 
a  triangular  piece  of  the  whole  thickness  of  the  eyelid,  and  then 
bringing  the  edges  of  this  incision  together  by  stitches,  so  as  to 
make  the  lid  sit  close,  as  in  the  natural  state,  upon  the  eyeball,  we 
should  merely  lose  our  labor  ;  for  the  disease  of  the  bone  not  being 
removed,  the  eyelid  would  very  soon  leturn  to  its  former  malpo- 
sition. 


!  SECTION    III. PEUIOSTOSIS,     HYPEROSTOSIS,    EXOSTOSIS,     AND 

OSTEO-SARCOMA    OF    THE    ORBIT. 

Periostosis  signifies  a  thickening  c f  the  perioste-  ra  ;  hyperostosis 
an  increase  of  the  bulk  or  thickness  of  bones  ;  exostosis,  a  bony  tu- 
mour ;  osteo-sarcoma,  a  malignant  degeneration  of  bone,  in  which 
it  is  converted  into  a  soft  mass,  having  numerous  osseous  spiculse 
radiating  through  it. 

1.  Periostosis. 

Venereal  nodes  on  the  tibia  are  examples  of  periostosis.  Similar 
nodes  are  sometimes  strumous.*     They  may  take  place  on  the 

*  Periostosis  of  the  tibia  is  occasionally  met  with  as  an  attendant  on  stnamous  cor- 
neitis. 


36 

face  of  any  bone :  on  the  external  surface  of  the  skull,  or  within 
the  orbit. 

2.  Hyperostosis 

Is  a  consequence  of  inflammation  of  a  bone  ;  this  process  having 
been  arrested  before  the  occurrence  of  disorganization  or  death  of 
the  part.  It  is  hyperostosis  which  in  some  cases  slowly  thickens 
the  iDones  of  the  cranium,  without  perhaps  exciting  any  suspicion 
of  the  existence  of  such  a  state,  till  epilepsy,  or  mania,  and  ultimate- 
ly death,  are  produced.  The  bones  of  the  orbit  are  liable  to  the 
same  process  ;  the  cavity  of  the  orbit  will  thereby  be  intruded  up- 
on :  its  contents  pressed  upon  :  and  the  eyeball  pushed  forw^ards 
from  its  natural  place,  and  ultimately  destroyed. 

We  are  indebted  to  Mr.  Howship  for  the  case  of  a  stout  healthy- 
looking  man,  59  years  of  age,  who  lost  his  eyes  from  hyperostosis 
of  each  orbit.  He  dated  the  origin  of  his  complaint  to  a  period  14 
years  before  Mr.  H.  saw  him,  which  was  in  1811.  He  was  in 
perfect  health,  and  on  a  windy  day  was  walking  up  Hampstead 
Hill.  On  the  road  he  was  suddenly  attacked  with  a  violent  itch- 
ing and  heat  in  both  his  eyes,  w'hich  induced  him  to  rub  them 
most  veheixiently.  Before  he  could  reach  home,  the  irritation  had 
increased  to  that  degree  that  he  was  unable  to  open  his  eyes  in  the 
light.  Inflammation  supervened,  and  a  small  tumour  formed  just 
below  the  inner  angle  of  each  eye,  about  the  size  of  a  hazel-nut. 
These  swellings  burst  inwardly,  discharging  afterwards  freely  be- 
tween the  eyelids.  The  inflammation,  treated  by  fomentations 
with  poppy  heads,  and  other  occasional  medicines,  went  on  for 
about  12  weeks.  It  had  then  so  far  subsided  that  he  could  open 
his  eyes,  and  bear  the  hght  tolerably  well,  so  that  he  went  to  work 
again.  About  a  fortnight  after  this,  having  been  exposed  all  night 
to  cold  and  rain,  in  the  winter  season,  he  had  a  fresh  attack.  He 
applied  to  Mr.  Ware,  who  ordered  a  warm  poultice  over  each  e)^e. 
as  the  swellings  were  again  returning  on  each  side  of  the  upper 
part  of  the  nose.  This  treatment  was  continued  for  about  six 
wrecks,  when  the  abscess  at  the  angle  of  the  right  eye  burst,  evac- 
uating its  contents  upon  the  cheek.  Two  weeks  afterwards,  that 
upon  the  left  side  broke,  and  a  copious  discharge  followed.  The 
formation  of  these  abscesses,  particularly  that  upon  the  left  side,  was 
attended  with  pains  in  the  head,  the  severity  of  which  he  could 
compare  to  nothing  but  the  sensation  of  his  head  splitting  asunder. 
These  pains  spread  also  through  the  bones  of  his  face.  During 
this  attack  he  could  get  no  rest  day  or  night  for  the  space  of  three 
months.  A  considerable  degree  of  projection  or  tumour,  apparently 
osseous,  was  now  observable  below  the  inferior  margin  of  each  or- 
bit, and  the  eyes  had  become  much  more  prominent  than  natural. 
He  was  at  this  time  a  patient  in  St.  Bartholomew's  Hospital, 
where  his  case  excited  much  attention.  One  day,  one  of  the  pu- 
pils observing  the  right  eye  thrust  out  of  the  orbit,  proceeded  to 
examine  it  rather  hastily,  when,  as  he  pressed  the  tumour,  and 


37 

pushed  back  at  the  same  time  the  eyehd,  the  globe  of  ttie  eye  sud- 
denly sprung  out  beyond  the  palpebree.  With  some  difficulty  it 
wa.s  reduced  again.  At  this  time  he  had  some  power  of  perceiving 
light  with  the  right,  but  more  with  the  left  eye.  The  pains  in  his 
head  and  face  continued  so  severe,  that  he  was  frequently  almost 
distracted.  The  inflammation  upon  the  eyes  was  still  violent,  par- 
ticularly that  upon  the  left.  He  was  often  delirious,  and  it  was 
sometimes  with  difficulty  that  he  was  prevented  from  tearing  his 
eyes  out,  in  the  rage  of  pain  and  delirium.  At  length  the  right 
eye  burst,  from  the  intensity  of  the  inflammation.  The  contents 
of  the  eyeball  having  escaped,  the  excessive  inflammation  declined, 
and  the  patient  became  somewhat  better.  The  osseous  tumours, 
however,  still  continued  to  grow,  although  their  increase  was  very 
slow.  Although  nothing  seemed  either  to  have  arrested  their  pro- 
gress, or  much  relieved  his  complaint,  he  now  found  his  general 
health  much  improved.  Some  time  after  this,  he  was  putting 
down  a  turn-up  bed,  and  not  being  able  to  see  what  he  was  about, 
the  bedstead  slipped  from  his  hand  and  fell,  one  of  the  feet  striking 
him  with  great  force  immediately  upon  the  ball  of  the  eye  that  was 
protruded,  and  lying  upon  the  hard  tumour  in  the  cheek.  By  this 
accident  the  globe  of  the  left  eye  was  burst,  but  he  suffered  no  par- 
ticular pain  at  the  moment,  beyond  the  mere  confusion  arising  from 
so  severe  a  blow  upon  the  face.  A  good  deal  of  inflammation, 
however,  soon  came  on,  but  subsided  again  spontaneously.  Sub- 
sequently to  this  period,  he  usually  enjoyed  very  good  health,  and 
in  1815  remained  well.  He  merely  observed  that  whenever  he 
took  cold,  it  was  particularly  apt  to  affect  his  head  with  a  transient 
return  of  his  old  inflammatory  pains.  On  separating  the  palpebree, 
the  tunicee  conjunctivae  still  retained  strong  marks  of  the  severe  in- 
flammation they  had  long  suffered.  The  tumours  of  the  maxillary 
bones,  feeling  as  hard  as  ivory,  and  not  in  the  least  painful  when 
pressed,  appeared  to  occupy  very  nearly  the  whole  space  of  each 
orbit,  as  well  as  the  cavities  of  the  nostrils,  which  were  almost,  if 
not  entirely,  obliterated.  In  the  integuments  covering  the  tumours, 
were  several  enlarged  and  varicose  veins.  From  the  slow  and  uni- 
form growth  of  the  swelUngs,  and  from  the  great  pain  that  attended 
their  production,  as  well  as  from  other  circumstances  connected 
with  the  history,  Mr.  H.  considers  that  there  is  every  reason  to  be- 
lieve that  the  original  affection  was  the  means  of  exciting  a  copious 
secretion  of  osseous  matter,  of  a  more  dense  texture  than  is  natural 
to  the  parts  ;  a  change,  he  observes,  which  generally  results  from 
healthy  ossific  inflammation.* 

3.     Exostosis 
Is  a  circumscribed  tumour,  consisting  of  newly  formed  osseous 
matter.     A  preUminary  step  in  the  process  by  w'hich  an  exostosis 

*  Howship's   Practical   Observations   in  Surgery  and  Morbid  Anatomy,  p.  26. 
London,  1816. 


38 

is  formed,  is  the  deposition  of  cartilage.  Exostosis  within  the  orbit 
has  been  met  with  wholly  in  the  cartilaginous  state;  in  other  cases, 
the  tumour  is  partly  cartilaginous,  partly  osseous.  The  cartilagi- 
nous deposition  gradually  undergoes  the  change  which  converts  it 
into  bone.  Three  varieties  of  exostosis  have  been  distinguished; 
the  cellular,  the  craggy,  and  the  ivory;  the  first  presenting  an  ex- 
ternal crust,  within  which  are  numerous  bony  partitions,  together 
with  a  quantity  of  soft  substance,  and  occasionally  hydatids ;  the 
second  consisting  of  a  mixture  of  osseous  laminae  with  cartilage, 
but  without  any  shell;  the  third  white  and  dense  like  ivory.* 

Syinptonis.  Exostosis  springs  in  some  cases  from  the  edge  of 
the  orbit;  its  nature  is  recognized  by  the  touch  ;  and  as  it  grows, 
it  comes  to  cover  in  part  and  to  confine  the  eye.  Although,  in 
general,  the  touch  will  serve  to  discriminate  between  exostosis  in 
this  situation,  and  any  other  kind  of  growth,  I  may  mention  that 
I  have  seen  a  case  of  scirrhous  tumour  attached  to  the  edge  of 
the  orbit,  and  partly  within  its  cavity,  so  very  firm  in  its  consistence, 
and  unyielding  in  its  attachment,  as  to  have  been  taken  for  an 
exostosis,  previously  to  dividing  the  skin  for  its  extirpation. 

Exostosis  from  the  edge  of  the  orbit  is  sometimes  combined  with 
encysted  tumour,  of  which  1  had  an  instance  at  the  Eye  Infirmary, 
in  a  middle  aged  female.  The  encysted  tumour  had  existed 
from  infancy,  and  was  attended  w^ith  exostosis  from  the  edge  of  the 
frontal  bone,  preventing  the  patient  from  raising  the  upper  lid. 
After  a  gentle  mercurial  course,  the  exostosis  diminished  so  much 
as  to  permit  the  lid  freely  to  exercise  its  functions. 

Exostosis  may  spring  from  any  side  of  the  orbit.  We  might 
perhaps  suppose  it  more  likely  to  grow  from  the  floor  or  from  the 
temporal  side  of  that  cavity,  than  from  the  thin  bones  w'hich  form 
its  roof  and  nasal  side ;  but  this  does  not  appear  to  be  the  case. 
The  most  remarkable  symptoms  produced  by  an  exostosis  withia 
the  orbit  are  the  following  : — 

1.  Exophthalmos,  or  protrusion  of  the  eyeball.  This  is  one 
of  the  earliest  symptoms  of  any  kind  of  growth  within  the  orbit. 
Sometimes  the  eye  is  projected  directly  forwards,  even  when  the 
osseous  tuinour  is  afterwards  found  to  arise  not  from  the  bottom  of 
the  orbit,  but  from  one  or  other  of  its  sides.  More  frequently  the 
eyeball  is  pushed  forwards  and  to  one  side,  towards  the  nose  or 
temple,  upwards  or  downwards,  according  to  the  side  of  the  orbit 
giving  rise  to  the  exostosis. 

2.  Pain.  This  is  very  various  ;  nor  is  it  easy  to  explain  how 
some  suffer  so  severely,  even  from  a  small  exostosis  within  the 
orbit,  while  others  from  large  tumours  of  this  sort  suffer  but  little. 

3.  Amaurosis.  The  projection  of  the  eye  must  be  attended 
with  traction  of  the  optic  nerve ;  and  this,  along  with  the  pressure 
on  the  nerve  caused  by  the  tumour,  induces  obscurity  of  sight,  and 
at  length  blindness. 

*  See  Dr.  Cumin's  paper  in  the  Edin.  Med.  and  Surg.  Journal,  Vol.  xsiii. 


39 

4.  Change  of  form.  Exostosis  sometimes  increases  to  such  a 
lize  as  considerably  to  dilate  the  orbit,  advancing  so  as  to  be  felt 
»etween  the  edge  of  the  orbit  and  eyeball.  It  may  even  intrude 
ipon  the  nostrils,  upon  the  opposite  orbit,  or  upon  the  cavity  of  the 
;raniura,  so  as  to  prove  fatal. 

Diagnosis.     In  cases  of  exostosis  within  the  orbit,  it  is  often 
nipossible  to  decide  regarding  the  nature  of  the   disease,  before 
)roceeding  to  operate,  or  before  the  death  of  the  patient;   for  ex- 
ophthalmos, pain,  amaurosis,  and  deformity  of  the  orbit,  are  found 

0  arise  from  several  other  diseased  states  of  the  parts  besides  an 
)sseous  growth;  as  encysted  and  other  tumours,  fungus  of  the  max- 
Uary  sinus,  &c.  In  advanced  cases  of  fungus  of  the  maxillary 
iinus,  other  symptoms,  no  doubt,  attend  those  already  enumerated, 
IS  softening  of  the  palate,  distention  of  the  cheek,  and  obstruction 
)f  the  nostril,  which  may  serve  to  distinguish  suf.h  cases  from  any 

disease  confined  to  the  cavity  of  the  orbit.  But  between  an  encys- 
:ed  tumour,  not  yet  advanced  so  as  to  press  upon  the  eyelids,  and 

1  deep  seated  exostosis,  it  is  often  totally  impossible  to  discriminate. 
The  eyeball  is  merely  extremely  prominent,  and  the  patient 
deprived  of  the  sight  of  that  eye,  without  any  tumour  being  felt,  or 
any  other  diagnostic  symptom  being  present.  Neither  can  we 
pretend  to  decide  in  cases  of  this  dubious  kind,  whether  thickening 
merely  of  the  periosteum,  thickening  of  the  bones,  or  such  a  tumour 
IS  we  call  exostosis,  be  the  cause  of  the  exophthalmos. 

Prognosis.  The  venereal  and  strumous  periostosis  may  yield  to 
remedies ;  hyperostosis  is  not  likely  to  be  affected  by  any  treat- 
ment. The  cellular  exostosis  is  said  to  be  occasionally  destroyed 
by  suppuration  and  caries ;  any  such  change  can  scarcely  be 
expected  to  take  place  in  the  craggy,  and  much  less  in  the  ivory 
exostosis.  Nor  will  the  possibility  of  any  exostosis  being  destroyed 
by  inflammation,  ever  withhold  us  from  removing  such  tumour  by 
operation ;  for  its  spontaneous  destruction  must  be  uncertain  and 
tedious.  The  ivory  exostosis  is  much  slower  in  its  progress  than 
the  others,  and  sometimes  it  entirely  ceases  enlarging. 

Causes.  Besides  venereal  and  strumous  constitutional  disease, 
blows  and  other  injuries  have  been  known  to  give  rise  to  exostosis. 

Treatment.  This  must  consist  in  antivenereal  and  antistru- 
mous  remedies  ;  and  in  certain  cases,  an  attempt  should  be  made 
to  remove  exostosis  of  the  orbit  by  operation.  The  tumour  being 
exposed  by  an  incision  through  the  integuments,  and  between  the 
fibres  of  the  orbicularis  palpebrarum,  it  may  be  removed  with  a 
strong  scalpel,  a  small  chisel,  or  a  slender  pair  of  bone  forceps,  such 
as  those  used  by  Mr.  Lislon  for  the  excision  of  diseased  pieces  of 
bone.  This  operation  must  of  course  be  executed  very  cautiously, 
lest  the  thin  bones  of  the  orbit  be  fractured,  or  any  injury  done  to 
the  eyeball  or  its  nerves,  in  the  attempts  to  detach  tlie  exostosis. 
Although  cases  are  recorded,  in  which,  after  the  application  of  caus- 
tic to  an  exostosis  of  the  orbit,  the  tumour  has  mortified,  and  been 


40 

thrown  off  like  an  exfoliation,  we  must  regard  this  as  a  practice  to 
be  followed  only  when  immediate  detachment  of  the  diseased 
growth  appears  impracticable.  It  is  a  practice  attended  with  much 
more  pain,  and  is  much  less  manageable  than  the  use  of  the  chisel 
or  forceps. 

Under  certain  circumstances,  it  may  be  advisable  to  remove  the 
protruded  eyeball  in  cases  of  exoslosis  of  the  orbit ;  namely,  when 
vision  is  destroyed,  the  pain  distressing,  and  the  osseous  tumour 
probably  so  far  back  in  the  orbit,  that  it  could  not  be  extirpated. 
*  The  extirpation  of  the  protruded  eyeball  has  also  sometimes  been 
resorted  to,  in  cases  of  exostosis  of  the  orbit,  when  the  symptoms 
were  too  obscure  to  lead  to  any  decided  diagnosis. 

Cases.  The  cases  of  exostosis  of  the  orbit,  minutely  related, 
are  but  few  in  number.  I  shall  quote  the  most  remarkable,  as  each 
will  serve  to  illustrate  one  or  more  points  of  importance. 

1.  Exostosis  of  the  orbit  removed,  while  yet  cartilaginous. 
Exostoses  have  sometimes  been  removed  while  in  the  cartilaginous 
state,  lying  under  the  periosteum.  Mr.  Travers  mentions  that  he  . 
had  seen  several  cases  of  this  description  ;  the  tumour  presenting 
at  the  nasal  side  and  appearing  to  extend  to  the  bottom  of  the  or- 
bit, its  anterior  edge  thin  and  bound  down  by  the  orbital  circum- 
ference, but  the  tumour  itself,  from  its  compressing  the  eye  to 
blindness  and  pushing  it  out  of  the  orbit,  probably  possessing  con- 
siderable bulk.  He  once  removed,  he  tells  us,  a  tumour  of  this 
kind,  on  the  nasal  side  of  the  orbit,  scraping  it  clean  away  from 
the  bone.  It  was  of  the  hardness  of  cartilage,  and  of  great  extent. 
He  is  unable  to  say  whether  the  disease  returned,  having  lost  sight 
of  the  patient  soon  after  the  operation.  The  impression  he  had  of 
the  case  was  unfavourable,  fi-ora  the  character  as  well  as  the  ex-  s 
tent  and  connexions  of  the  tumour.* 

2.  Exostosis  of  the  orbit  destroyed  by  inflammation  excited  > 
by  the  tise  of  caustic.     Brassant's  case  is  often  referred  to.     The 
patient  was  a  woman,  30  years  of  age,  who  had  fruitlessly  under-  j 
gone  the  operation  for  fistula  lachrymalis.     Fifteen  years  after- 
wards, the  OS  planum  and  the  internal  angular  process  of  the  fron-  { 
tal  bone  presented  an  exostosis  of  the  size  of  an  egg.    The  globe  of 
the  eye,  compressed  laterally,  was  thrust  out  of  the  orbit,  and  hung 
in  some  measure  on  the  cheek  at  the  temporal  angle.     Brassant 
attacked  this  exostosis  with  caustic.     It  suppurated,  and  within  the 
space   of  from  3  to  4  months,    exfoliation  separated  a  considera- 
ble portion  of  the  bony  growth.     The  eye  returned  to  its  natural' 
situation,  and  the  cure  v/as  ultimately  perfect. t 

Professor  Sporing  has  recorded  a  case  of  osseous  excrescence, 
which  grew  from  the  bone  in  the  immediate  vicinity  of  the  inter- 
nal canthus.  The  patient  was  a  man  of  35  years  of  age.  The 
excrescence  grew  to  the  size  of  a  very  large  walnut,  pushing  the 

*  Travers's  Synopsis  of  the  Diseases  of  the  Eye,  p.  227,  London,  1820. 

t  Memoires  de  I'Academie  de  Chirurgie;  Tom.  xiii.  p.  277.  12mo.  Paris,  1774. 


I 

1  eye  nearly  out  of  its  socket,  and  impan-ing  vision.  A  surgeon  tried 
to  remove  it,  by  promoting  exfoliation ;  but  the  wound  bled  so 
freely,  that  he  was  happy  to  close  it  up  again.  Some  time  after- 
wards, a  peasant  was  allowed  to  try  his  skill  upon  it.  He  began 
with  an  incision  round  the  bone,  which  caused  a  great  effusion  of 
blood.  He  afterwards  applied  to  it  some  secret  remedy,  which  pro- 
duced intolerable  pain  for  12  days,  attended  with  faintings.  Sev- 
eral months  afterwards,  however,  the  patient  had  the  courage  to 
undergo  the  operation  again.  In  the  following  spring,  the  entire 
exostosis  dropped  out ;  the  eye  returned  to  its  situation  in  the  orbit, 
and  vision  was  restored.* 

3.  Exostosis  loosened  hy  operation,  atid,  after  12  months,  ex- 
tracted, carious,  from  the  orbit.  Mr.  Lucas  has  related  a  case 
of  bony  tumour,  arising  after  an  injury,  and  successfully  extracted 
from  the  orbit.  The  patient  was  a  farmer's  daughter,  28  years  of 
age.  On  the  25th  of  February  1802,  she  received  a  blow  from  a 
cow's  horn  on  the  upper  and  inner  angle  of  the  left  orbit,  nearly 
on  the  transverse  suture.  As  it  inflicted  no  wound,  and  the  pain 
soon  subsided,  it  was  considered  merely  as  a  slight  contusion,  and 
httle  attention  was  paid  to  it.  About  the  beginning  of  March, 
there  was  discovered  on  the  spot  where  the  blow  had  been  received, 
a  small  hard  tumour,  which  gradually  increased  in  size,  with  very 
little  pain  and  no  interruption  to  her  general  state  of  health,  so  that 
she  continued  her  usual  laborious  employments  about  her  father's 
house.  On  the  1st  of  October,  she  consulted  Mr.  L.,  who  found, 
covered  by  the  upper  eyelid,  a  very  hard  tumour,  of  an  oval  form, 
and  rather  flat,  somewhat  more  than  an  inch  in  its  perpendicular 
diameter,  and  extending  horizontally,  about  an  inch  and  a  half  in 
length,  from  the  inner  angle  of  the  orbit  towards  the  eyeball,  which 
was  displaced.  The  tumour  seemed  to  occupy  the  greater  part  of 
the  orbit,  and  had  forced  the  eye  forwards  and  outwards,  so  that  it 
hung  pendulous  and  loose,  and  apparently  entirely  beyond  the  ex- 
terior edge  of  the  outer  angle  of  the  orbit.  Mr.  L.  concluded  that 
the  optic  nerve  and  muscles  must  have  been  elongated  nearly  an 
inch.  She  could  still  discover  objects  with  the  eye,  although  its 
sight  was  much  impaired.  She  complained  of  little  pain,  even 
when  the  tumour  was  pressed  or  handled  pretty  freely.  Mr.  L. 
resolved  to  ascertain  the  nature  of  the  tumour,  which,  although 
hard,  appeared  somewhat  loose.  With  this  view,  he  made  a  hori- 
zontal incision  through  the  upper  eyelid,  about  an  inch  in  length, 
along  the  greater  diameter  of  the  tumour.  On  separating  and  rais- 
ing the  edges  of  the  wound,  the  tumour  was  discovered  to  be  a 
solid  piece  of  bone,  covered  only  by  the  common  integuments,  and 
a  thin  membrane  somewhat  resembling  periosteum,  to  which  the 
tumour  was  but  slightly  attached.     No  part  of  the  bones  of  the  or- 

*  Gluoted  from  Haller  by  Mr.  B.  Bell,  in  his  Treatise  on  the  Diseases  of  the  Bones ; 
page  121.  Edin.  1828.  Referred  to  also  by  Acrel.  I  have  not  been  able  to  find  the 
original  account  of  the  case. 

6 


42 

bit  was  denuded  :  and  although  the  manner  of  the  adhesion  of 
the  tumour  to  the  surrounding  parts  could  not  be  ascertained,  it 
remained  firm  and  immoveable,  notwithstanding  considerable 
efforts  to  loosen  it  and  bring  it  away.  The  wound  made  by  the 
incision  did  not  heal  up,  but  continued  nearly  of  its  original  size, 
discharging  a  small  cjuantity  of  thin  matter.  The  bone  continued 
to  increase  in  size,  and  the  eye  was  still  more  pushed  out  of  its 
natural  position,  although  some  degree  of  sight  still  remained  in 
it.  The  patient  continued  in  perfect  health.  At  length,  towards 
the  end  of  September,  1803,  the  bone  becoming  carious  and  evi- 
dently loose,  and  pushing  somewhat  forwards,  Mr.  L.  endeavored 
to  extract  it,  by  making,  wiih  a  small  scalpel,  an  incision  around 
the  edges  of  the  former  wound,  to  detach  it  from  any  adhesion  at 
its  orifice,  and  then  taking  firm  hold  of  the  exostosis  with  a  pair  of 
strong  forceps.  The  first  attempt  failed  ;  but  a  second,  made  sev- 
eral days  afterwards,  succeeded.  Mr.  L.  extracted,  without  much 
exertion  or  difficulty,  a  piece  of  bone,  of  an  oblong  shape,  weighing 
an  ounce  and  two  drachms,  an  inch  and  a  half  in  length,  and  2 
inches  f  ths  in  circumference,  hard,  solid,  and  pretty  smooth.  The 
extraction  of  the  bone  was  followed  by  no  haemorrhage  ;  a  few 
drops  of  blood  only  were  discharged  from  the  edges  of  the  wound. 
The  cavity  from  which  it  was  extracted  was  found  to  be  lined  with 
a  strong  membrane,  cjuite  smooth  on  the  upper  and  inner  sides, 
but  somewhat  uneven  on  the  side  next  the  ball  of  the  eye.  No 
perforation  or  communication  with  any  of  tlie  surrounding  parts 
could  be  discovered  in  it :  when  examined  both  with  a  probe  and 
the  finger,  little  irritation  or  pain  was  produced,  and  the  bone  had 
evidently  no  connexion  or  adhesion  with  any  bone  adjoining  to  it. 
In  March,  1805,  when  Mr.  L.  published  his  account  of  the  case, 
the  wound  was  still  open,  and  the  cavity  still  extended  in  a  straight 
direction  backwards  to  two  inches  in  depth.  A  little  lint,  covered 
by  a  bit  of  silk,  hid  the  deformity.  Ever}^  time  the  dressing  was 
removed,  the  inside  of  the  cavity  was  found  to  be  covered  with  a 
slight  exudation.  The  eyeball  had  in  a  great  measure  recovered 
its  natural  situation,  and  the  sight  of  the  eye  had  been  complete!)'' 
restored.*  The  bone  extracted  in  this  case  was  particularly  ex- 
amined and  analyzed  by  Dr.  Duncan,  junior,  who  hns  also  pub- 
lished two  figures  illustrating  its  external  appearance  and  internal 
structure.  Its  shape  he  represents  as  extremely  iiTegular,  but 
somewhat  resembling  a  wedge  cut  out  of  a  sphere.  The  convex 
back  of  the  wedge,  which  was  turned  towards  the  middle  line  as 
it  lay  in  the  orbit,  although  extremely  irregular  and  studded  with 
processes,  was  in  general  smooth  and  polished.  The  sides  were 
concave  and  much  less  uneven,  but  in  no  part  had  a  smooth  cr 
polished  surface.  They  resembled  those  points  of  bone  to  which 
cartilage,  ligament,  or  membrane  is  firmly  attached,  being  full  of 

•  Edinburgh  Medical  and  Surgical  Journal,  Vol.  i.  p.  405.    Edin.  1805. 


43 

;mall  pits  or  depressions,  and  rough,  as  if  corroded  by  the  action 
)f  a  caustic  fluid.  In  no  part,  after  the  most  careful  examination, 
ltd  it  show  any  appearance  of  fracture,  and  therefore  (conchides 
Dr.  D.)  could  not  have  been  an  exostosis.  Its  colour  was  yellow- 
sh-white ;  its  saw-dust  snow-white.  It  was  extremely  hard. 
When  cut,  its  internal  structure  was  found  to  be  nearly  uniform, 
;om3what  like  that  of  ivoiy,  being  very  slightly  marked  with  the 
ippearance  of  radii,  extending  from  the  middle  of  the  edge  to  the 
;onvex  back  of  the  wedge.  It  admitted  of  being  polished  like 
vory.  In  specific  gravity  and  chemical  composition,  it  scarcely 
liffered  froui  a  piece  of  adult  os  femoris.*  That  this  was  an  osse- 
)U3  tumour  formed  without  any  connexion  with  the  bones  or  peri- 
)steumofthe  orbit,  is  extremely  improbable.  I  have  not  hesi  ated 
0  quote  it  as  a  case  of  exostosis,  notwithstanding  Dr.  D.'s  opinion 
0  the  contrary.  That  it  had  before  its  extraction  become  loosened, 
lot  altogether  by  fracture,  but  at  least  partly  by  absorption,  from 
my  connexion  it  might  have  had  with  the  walls  of  the  orbit,  is 
'ery  evident.  It  must  also  be  kept  in  mind,  however,  that  when 
\Ir.  L.  first  attempted  to  extract  it,  it  was  so  immoveable,  that  he 
;ould  not  loosen  it,  to  bring  it  away.  To  what  could  its  immobil- 
ty  be  owing,  but  to  its  adhesion  to  the  walls  of  the  orbit  ?  That 
idhesion  might  have  been  cartilaginous  or  even  osseous  ;  and  yet 
ifter  being  allowed  to  become  carious  and  to  grow  loose,  during 
he  course  of  a  whole  year,  the  piece  of  bone  might,  on  extraction, 
jresent  no  mark  of  fracture.  Even  at  the  end  of  a  year  after  his 
irst  operation,  Mr.  L.  did  not  succeed  in  his  first  attempt  to  extract 
fc.  At  his  second  trial,  he  did  succeed,  and  found  the  cavity  in 
vhich  the  bone  had  been  lodged  smooth,  except  towards  the  eye- 
)all.  Of  course  it  is  impossible  to  decide,  with  certainty,  how 
his  bone  grew  ;  but  I  regard  it  as  much  more  probable  that  it 
vas  an  exostosis  separated  from  its  point  of  growth,  by  the  frequent 
ixarainations  which  bad  been  made  of  it  by  Mr.  L.  and  others, 
uid  by  the  attempt  first  made  by  that  gentleman  to  extract  it, 
,han  that  it  was  a  formation  of  bone  in  the  cellular  membrane  of 
he  orbit,  entirely  unconnected  with  the  walls  of  that  cavity. 

4.  Exostosis  of  the  orbit  7iot  discovered  till  after  extirpation 
f  the  protruded  eyeball.  Dr.  Anderson  has  related  a  case  of  ex- 
)phthalmos,  arising  from  exostosis  on  the  floor  of  the  orbit.  The 
jatient,  Mrs.  Craig,  aged  24,  was  admitted  into  the  Glasgow  Royal 
[nfirmary,  5th  January,  1828  ;  at  which  time  the  right  eyeball 
,vas  almost  protruded  out  of  the  orbit.  As  I  had  occasion  to  see 
.his  patient  before  she  went  to  the  Royal  Infirmary,  I  may  men- 
ion  that  the  protrusion  was  directly  forwards,  so  that,  though  the 
dea  of  the  exophthalmos  probably  depending  on  exostosis  of  the 
Drbit,  naturally  occurred  to  my  mind,  I  could  not  have  been  led  to 
issign  any  one  of  the  sides  of  that  cavity  more  than  another  as 

*  Edinburgh  Medical  and  Surgical  Journal,  Vol.  i.  p.  407.    Edin.  1805. 


44 

likely  to  be  the  seat  of  such  a  growth.  Ectropium  tirid  cheraosis 
attended  the  protrusion.  The  cornea  was  ulcerated  and  muddy; 
the  pupil  imraoveably  dilated,  and  vision  lost.  The  patient  had 
constant  severe  pain  in  the  bones  of  the  orbit,  and  right  side  of 
the  head,  rendered  more  acute  by  pressure.  She  had  rheumatic 
pain  of  the  knees.  Her  health  was  greatly  impaired,  but  had  im- 
proved since  her  delivery  8  weeks  before  her  admission.  The  vis- 
ion of  the  eye  had  been  dim  for  18  months,  and  completely  lost  for 
4.  The  pain  of  the  head  was  of  12  months'  standing,  and  the 
prominence  of  the  eye  of  8  weeks'.  She  had  had  some  discharge 
of  yellow  fluid  from  the  right  ear.  about  the  time  when  the  sight 
was  lost,  but  not  afterwards.  Her  mouth  was  affected  by  pills 
which  she  had  taken  for  five  or  six  weeks.  Dr.  A.  suspected  syph- 
ilis, but  she'  denied  it :  and  as  the  mercury  seemed  to  have  had 
little  other  effect  tha.n  that  of  increasing  debihty.  he  suspended  its 
use,  and  endeavoured  to  procure  relief  from  other  medicines  and 
external  applications,  chiefly  opiates  and  narcotics.  These  did  not 
succeed.  He  then  evacuated  the  humour.-?  of  the  eye,  but  this  also 
was  ineffectual.  He  next  extirpated  the  eye  with  the  knife,  after 
which,  a  tumour  about  the  size  of  a  hazel-nut  was  discovered  on 
the  floor  of  the  orbit,  solid,  nodulated,  and  bony.  The  pressure  of 
this  exostosis  had  been  the  cause  of  the  pain  and  protrusion,  but  as 
it  was  firmly  fixed,  and  could  not  now  exert  any  injurious  pressure, 
it  was  not  considered  prudent  to  attempt  its  removal.  From  some 
inflammation  and  fulness  in  the  right  nostril.  Dr.  A.  had  been  led 
to  suppose  it  likely,  that  there  might  have  been  a  fungous  or  other 
tumour  pushing  upwards  from  the  antrum  to  the  orbit.  The  relief 
from  pain  was  remarkable  after  the  extirpation  of  the  eye.  Plum- 
mer's  pill,  and  a  decoction  of  sarsaparilla,  were  now  used  for  several 
weeks,  during  which  time  the  patient  got  almost  quite  well ;  but 
whether  this  proceeded  from  the  removal  of  the  eye,  the  discharge 
which  succeeded  it,  or  the  medicine.  Dr.  A.  does  not  decide.  He 
believes  that  all  of  these  were  useful.  It  was  his  intention  to  have 
advised  the  insertion  of  a  pea  issue  in  the  neck,  and  a  continuance 
of  the  medicine,  but  ihe  patient  left  the  Infirmary  on  the  1st  of 
March,  without  receiving  these  instructions.  At  that  time,  her 
health  was  good,  and  there  was  no  appearance  of  increased  growth 
in  the  orbit.* 

5.  Exostosis  filling  the  orbit.  Dr.  Baillie,  in  his  Series  of  En- 
gravings illustrative  of  Morbid  Anatomy,  has  given  a  figure  of  a 
preparation  of  exostosis  of  the  orbit  belonging  to  Mr.  Hunter's  mu- 
seum. The  figure  represents  an  inner  view  of  a  section  of  the  fore 
part  of  the  cranium.  The  section  had  been  made  at  such  a  level, 
as  to  include  a  small  part  of  each  orbit.  A  tuniour  is  represented 
as  occupying  the  left  orbit,  which  it  has  considerably  dilated,  and 
shcotiog  for  some  way  across  into  the  other  orbit,  and  backwards 

"  Glasgow  Medical  Journal,  Vol.  i.  p.  319.  Glasgow,  1828. 


45 

into  the  cavity  of  the  cranium.  Dr.  BailHe  mentions  that  the 
tumour  was  nodulated,  and  presented  a  compactness  of  texture 
exactly  like  that  of  ivory.  Unfortunately  no  history  of  the  case  ap- 
i  pears  to  have  been  preserved.  It  bears  a  certain  degree  of  resem- 
blance to  the  remarkable  case  of  hyperostosis  of  the  orbits  already 
,  quoted  from  Mr.  Hovvship*.  Dr.  B.  has  hazarded  a  conjecture  re- 
garding it,  for  which,  1  should  think,  there  is  scarcely  any  founda- 
tion, namely,  that  perhaps  this  tumour  consisted  of  the  eye  convert- 
ed into  bone.t 

6.  Extostosis  'proceeding  from  the  Tnaxillary  sinus  into  the 
orbit.  Boyer  relates  the  case  of  a  man,  who  for  more  than  ten 
3'ears  had  an  exostosis  of  the  left  maxillary  sinus.  The  eye  on  that 
side  was  affected  with  stillicidium  lachryrnarum.  The  eyeball  was 
pushed  forward,  the  nose  twisted  to  the  right,  the  nostril  closed,  and 
the  palate  somewhat  swollen.  The  tumour  was  very  prominent 
upwards  and  outwards,  and  the  skin  covering  it  red  and  shining. 
The  visage  was  excessively  deformed.  The  exostosis  had  appear- 
ed soon  after  a  venereal  infection,  which  had  been  followed  by  sec- 
ondary symptoms.  It  had  increared  slowly  ;  but  for  several  years 
had  made  no  progress.  Painful  at  first,  it  had  ceased  to  be  so  when 
it  stopped  growing.  The  patient,  of  his  own  accord,  resolved  to 
try  fully  the  effect  of  the  liquor  of  Van  Swieten  ;  and  after  having 
taken,  without  any  medical  advice,  and  in  less  than  three  months, 
128  grains  of  corrosive  sublimate,  he  was  entirely  freed  of  the  ex- 
ostosis. The  eye  returned  into  the  orbit,  the  stillicidium  ceased, 
and  the  nostril  became  free.  A  depression  on  the  cheek,  and  an 
adhesion  of  the  skin,  marked  what  had  been  the  situation  of  the 
tumour.t 

Sir  Astley  Cooper  observes,  that  exostosis  of  the  facial  bones  is 
of  frequent  occurrence.  He  mentions,  that  in  the  collection  at  St. 
Thomas's,  there  is  the  skull  of  a  fish-woman,  who  died  in  that  hos- 
pital, and  who  had  long  been  remarkable,  even  at  Billingsgate,  for 
her  hideous  appearance-  Two  large  sweUings  had  been  formed 
under  the  orbits  in  the  forepart  of  the  cheeks,  between  which  the 
nose  appeared  wedged,  and  the  nostrils  were  closed.  Each  eye 
projected  considerably  from  its  socket.  This  person  was  seized  with 
a  fit,  which  seemed  to  be  of  an  apoplectic  nature,  and  in  that  state  was 
brought  to  St.  Thomas's  hospital,  where  she  died  almost  immedi- 
ately. Upon  examination  of  the  head,  an  exostosis  was  found 
growing  from  each  antrum,  and  forming  the  large  swellings  upon 
the  cheeks.  The  exostoses  projected  also  into  the  orbits,  so  as  to 
occasion  the  protrusion  of  the  eyes.  On  the  left  side,  the  exostosis 
entered  the  cranium,  projecting  inwards  through  the  orbitary  pro- 
cess of  the  OS  frontis,  and  occasioning  such  pressure  on  the  brain, 

*  See  page  36. 

t  Baillie's  Series  of  Engravings,  Fasciculus  x.  Plate  I.     Also  his  Morbid  Anatomy, 
p.  446.    London,  1812. 
X  Boyer,  Traite  des  Maladies  Chirurgicales.  Tome  vi.  p.  168.    Paris,  1818. 


46 

as,  under  a  considerable  excitement  of  the  vessels  of  that  organ,  to 
produce  apoplexy,  which  proved  fatal.* 

I  recollect  a  very  remarkable  skull,  which  was  presented  by  Pro- 
fessor Sue  to  the  Museum  of  the  Ecole  de  Medicine  at  Paris,  where 
it  is  still  preserved.  It  has  been  described  t  as  an  example  of  osteo- 
sarcoma, but  1  think  there  can  be  scarcely  any  doubt  of  its  being 
an  exostosis  of  the  maxillary  sinus.  The  osseous  tumour,  which 
is  actually  not  much  less  than  an  ordinary  cranium,  is  smooth  and 
polished  externally,  very  thin  at  its  upper  part,  hard  and  covered  with 
bosses  posteriorly,  and  interiorly  filled  with  osseous  cysts.  It  springs 
from  the  right  maxillary  sinus  and  lower  part  of  the  frontal  bone, 
and  extends  from  the  right  mastoid  process  towards  tlie  left  maxil- 
lary bone.  No  trace  is  to  be  seen  of  the  right  orbit ;  the  right  nos- 
tril is  entirely  obliterated  ;  as  well  as  a  portion  of  the  left  orbit. 
The  tumour  proceeds  downwards  and  forwards  from  its  origin,  to 
a  level  with  the  basis  of  the  lower  jaw,  measuring  from  the  mastoid 
process  12  inches  in  length,  and  in  circunjference  16  inches. 

7.  Exostosis-  from  the  facial  hones  shuttivg  vp  the  orbits. 
Jourdain  has  related  and  figured  a  remarkable  case  of  exostosis  of 
the  bones  of  the  skull,  and  especially  of  those  of  the  face.  The 
patient  was  the  son  of  a  surgeon  at  Perpignan,  At  the  age  of  12 
years,  he  was  affected  with  a  lachrymal  tumour  at  the  inner  angle 
of  the  right  eye,  which  his  father  opened,  and  which  suppurated  for 
a  pretty  long  time.  When  the  tumour  was  opened,  an  eminence 
was  observed  growing  from  the  middle  of  the  nasal  process  of  the 
upper  maxillary  bone,  about  the  size  of  a  small  almond.  It  resist- 
ed different  local  applications,  and  grew  insensibly,  so  that  in  a 
short  time  it  was  a  considerable  tumour.  By  the  time  that  the  pa- 
tient was  15,  his  two  upper  niaxillory  bones  were  equal,  and  pre- 
sented two  eminences  so  considerable,  that  they  served  to  bury  be- 
tween them  the  cartilages  of  the  nose,  and  so  compressed  the  nos- 
trils, that  the  patient  could  breathe  only  by  the  mouth.  His  school- 
fellows could  not  endure  the  deformity  of  his  face ;  3'et  they 
loved  him  for  his  wit  and  talents.  Every  thing  was  done  by  his 
father  which  was  likely  to  remove  the  disease  ;  but  all  was  ineffect- 
ual. By  the  age  of  20,  his  appearance  was  monstrous,  so  that  his 
friends  dissuaded  him  from  thinking  of  the  priesthood,  to  Avhich  he 
had  intended  to  attach  himself  His  lower  jaw  was  also  affected 
with  an  enlargement,  which  augmented  more  and  more.  Although 
his  appearance  was  such  as  to  oblige  those  who  met  him  to  turn 
awa}^  from  looking  at  him,  he  was  very  curious,  and  would  visit 
every  thing  which  excited  attention.  He  ate  and  drank  well,  till 
having  reached  his  44!h  year,  he  was  attacked  with  fever ;  during 
his  convalescence  from  which  he  became  blind.  As  he  recovered 
strength,  he  began  to  see  with  the  left  eye,  and  to  go  about  alone  ; 

*  Surgical  Essays,  by  Cooper  and  Travers.  Vol.  i.  p.  169.     London,  1818. 
i  Dictionaire  des  Sciences  Medicales.    Toinexxxv.  p  25.     Paris,  1819. 


47 

! but  inflammation  of  the  chest  supervening,  with  suppuration,  and 
bloody  expectoration,  he  died.  On  dissection,  the  left  lung  was 
found  almost  entirely  destroyed  by  suppuration.  With  the  greatest 
attention,  it  Avas  impossible  to  discover  any  of  the  muscles  of  the 
I  face.  The  skin  was  glued  to  the  periosteum.  The  cranium  and 
face  were  entirely  exostosed.  Tlie  malar  bones  especially  appear; 
from  Jourdain's  tigure,  to  have  each  given  rise  to  a  large  exostosis, 
projecting  so  as  to  meet,  covering  the  nose,  and  in  a  great  measure 
the  orbits.  The  lower  jaw  also  is  exceedingly  enlarged.  The 
exostoses  were  as  hard  as  marble.  The  cranium  and  face  weighed 
5  French  pounds;  the  lower  jaw  by  itself  weighed  3  pounds  3 
ounces ;  the  whole  together  8  pounds  3  ounces  ;  whereas,  an  ordi- 
nary adult  skull,  including  the  lower  jaw,  Aveighs  generally  about 
|1  pound  9  ounces,  or  at  most  1  pound  and  3  quarters,  so  that  tak- 
ling  the  pound  at  16  ounces,  the  exostoses  had  augmented  the  weight 
bf  the  head  6  pounds  7  ounces.  This  patient  had  never  complain- 
ed of  pain  in  his  head  nor  in  his  lower  jaw.* 

■  8.  Caplike  exostosis  of  t!ie  edge  of  the  orhit.  Acrel  relates  a 
'ase  of  this  sort  under  the  title  of  Spina  Yentosa  of  the  right  orbit. 
The  bones  forming  that  cavity,  especially  the  frontal  and  superior 
uaxillary,  were  so  much  protruded,  as  to  present  the  appearance 
)f  a  blunt  cone,  four  fingers'  breadtli  high,  and  about  the  same  in 
liameter  at  its  basis.  He  compares  it  to  a  small  cup  inverted,  in 
he  bottom  of  which,  or  end  which  w^as  turned  outwards,  was  the 
iye.  It  was  not  completely  sound  and  clear,  and  was  smaller  than 
he  left  eye  ;  yet  it  had  eyelids,  which  were  moveable,  and  the  other 
Darts  belonging  to  it,  and  even  served  to  distinguish  large  objects 
)retty  well.  Acrel  considered  the  case  incurable.  He  mentions 
hat  he  had  seen  another  case  of  the  same  sort,  for  which  also  he 
egarded  it  as  useless  to  attempt  any  operation.t 

4.   Osteosarcoma, 

By  some  cdXleA  fibrous  exostosis,  and  by  Sir  Astley  Cooper /wn- 
jous  exostosis  of  the  medullar y  metnhrane,  sometimes  attacks 
he  skull,  and  may  involve  the  bones  of  the  orbit.  This  kind  of 
umour  takes  its  rise  within  the  spongy  tissue  of  the  bones,  consists 
»f  a  substance  much  softer  than  ordinary  cartilage,  containing  nu- 
nerous  slender  spiculse,  or  thin  plates  of  bone,  radiating  through  it, 
lepends  on  a  particular  state  of  constitution,  and  appears  invariably 
0  be  malignant. 

Dr.  Baillie  has  figured  a  skull  affected  with  several  tumours  of 
his  sort ;  one  of  which  had  its  seat  close  upon  the  right  exter- 
lal  angular  process  of  the  frontal  bone.t 


♦  Jourdairi,  Traite  des  Maladies  de  la  Bouche,  Tome  i.  p.  289.     Paris,  1778. 
t  Acrel,  Chirurgische  Vorfalle,  Uberselzt  von  Murray.     Vol.  i.  p.  102.  Gottingen, 
777. 
t  Baillie's  Series  of  Engravings.    Fasciculus  x.  Plate  1. 


48  I 

Sir  Astley  Cooper  has  given  a  sketch  of  an  osteo-sarcomatous 
tumour  on  the  forehead,  extending  close  to  the  edge  of  the  orbit. 
Sir  A.  persuaded  the  subject  of  this  tumour  to  submit  to  an  opera- 
tion. On  removal,  it  was  found  exactly  of  the  character  above 
mentioned,  and  although  partly  formed  of  osseous  spiculae,  was 
readily  broken  down  with  the  finger.  The  patient  became  feverish 
and  comatose,  and  died  on  the  6th  day.  On  dissection,  Sir  A 
found  that  the  swelling  occupied  the  internal  as  well  as  the  exter- 
nal table  of  the  skull,  that  it  extended  through  both,  and  affectet 
the  dura  mater,  which  had  several  fungous  projections  proceeding 
from  it,  and  that  the  inflammation  excited  by  the  operation,  hac 
extended  to  the  membranes  of  the  brain.  The  complaint  seemec 
to  have  originated  in  the  diploe  of  the  os  frontis,  and  to  have  pro  i 
duced  an  effusion  both  between  the  pericranium  and  the  skull,  anc ; 
between  the  skull  and  the  dura  mater.  The  ewelUng  upon  th( 
outer  part  of  the  head,  was,  however,  much  larger  than  that  whicl 
had  arisen  from  the  inner  table.  It  was  evident,  too,  that  this  case 
must  have  ultimately  proved  fatal,  although  no  operation  had  beer 
performed.  Sir  A.  concludes  by  observing,  that  an  exostosis  on  thi 
external  table  of  the  skull,  growing  slowly,  very  little  vascular,  un 
attended  with  any  considerable  pain,  may  safely  be  rendered  th( 
subject  of  an  operation  ;  but  that  a  swelUng  of  more  rapid  growth 
red  upon  its  surface,  showing  signs  of  considerable  vascularity,  an( 
attended  with  great  pain  shooting  through  the  brain,  is  one  fo 
which  he  should  hesitate  again  to  perform  an  operation.*  Thes' 
latter  characters  belong  not  to  simple  exostosis,  but  to  osteo-sarcoma 

Mr.  Crampton  relates  that  he  v.-as  consulted  by  a  lady  of  abou 
55  years  of  age,  on  account  of  dimness  of  sight  affecting  the  righ 
eye  ;  the  eye  felt  exceedingly  hard  to  the  touch,  was  af!ected  by  stra 
bismus,  and  projected  in  some  degree  from  the  orbit ;  the  pupil  wa 
immoveable,  but  vision  was  not  altogether  destroyed.  She  com 
plained  of  severe  shooting  pains  in  the  head  and  in  the  right  arm 
her  general  health  v.^as  much  affected,  and  her  aspect  almost  C8 
daverous :  her  memory  seemed  much  impaired,  and  there  was 
general  insensibility  to  external  impressions  ;  she  was  depressed  i; 
her  spirits,  yet  she  made  but  httle  complaint.  On  an  attentive  ex 
amination  it  was  plain  that  there  was  some  fulness  in  the  situatioj 
of  the  temporal  fossa,  but  the  tumour  was  perfect!}^  indolent  an 
incompressible.  Mr,  C.  did  not  see  the  lad}'  again  for  4  or  5  week: 
when  he  found  her  nearly  comatose;  the  swelling  on  the  tempi 
had  increased  to  a  considerable  degree,  and  the  eye  was  still  furthe 
protruded  from  the  orbit.  She  expired  in  a  few  days,  and  on  th 
day  following  her  death,  the  head  was  examined.  On  raising  th 
aponeurosis  of  the  temporal  muscle,  the  temporal  fossa  was  foun 
to  be  occupied  by  a  grayish  coloured  substance  of  the  consistence  ( 
brain  ;  the  muscle  itself   had    completely  disappeared :  numerot 

•  Surgical  Essays,  by  Cooper  and  Travers.     Vol.  i.  p.  212.     Lend.  1818. 


49 

|)sseous  spiculee  proceeding  from  the  frontal  and  temporal  bones, 
)assed  into  the  tumour,  of  which  they  constituted  a  considerable 
)art.     On  opening  the  head,  a  tumour  of  precisely  the  same  de- 
icription,   beset  in  the  same  manner  by  bony  spiculee,  was  found 
edged  between  the  dura  mater  and  the  internal  orbital  process  cf 
J*;  he  frontal  bone.     On  macerating  the  bone,  it  exhibited  the  most 
|i  Perfect  specimen  Mr.  C.  had  seen  of  the  fibrous  exostosis.     The 
.  ipiculee  proceeding  both  from  the  outer  and  from  the  inner  table  of 
he  cranium  were  each  about  as  thick  as  a  hog's  bristle,  and  f  ths 
)f  an  inch  in  length  ;  they  were  set  as  closely  together  as  the  hairs 
)f  a  brush,  and  extended  in  an  undulating  line  over  a  space  of 
I  bout  two  square  inches  in  extent.     The  tables  of  the  skull  were 
ilightly  separated  from  each  other  in  the  part  corresponding  to  the 
exostosis,  and  the  diploe  seemed  to  contain  some  of  the  same  brain- 
ike  matter  which  formed  the  bulk  of  the  tumour.     Mr.  C.  thinks 
t  impossible  to  decide  whether  the  disease  commenced  in  the  soft 
Darts,  or  in  the  bone ;  although  it  seems  to  him  probable  that  it 
i  ;ommenced  in  the  bone,  because  the  spiculae  were  furnished  by  the 
3one  itself,  and  not  by  the  periosteum  or  dura  mater,  which  were 
separated  by  the  tumour  to  the  distance  of  nearly  an  inch  from 
he  outer  and  inner  tables  of  the  skull  respectively.     Mr.  C.  ob- 
serves that  in  malignant  osteo-sarcoma,  it  is  more  usual  to  find  a 
deficiency  than  an  excess  of  bony  matter,  for  although  spiculee  of 
jone  are  interspersed  through  the  brain-like   matter  which  forms 
iLhe  bulk  of  the  tumour,  the   bone  itself  is  usually  divested  of  its 
3arthy  basis,  and  is  converted  into  a  steatomatous  or  cartilaginous 
substance.     Sometimes,  however,  the  tendency  to  secrete  phosphate 
bf  lime  is  surprisingly  increased,  and  then  large  and  singulaily 
I  shaped  masses  of  bony  matter  are  thrown  out  from  the  surface  of 
Lhe  diseased  bone.     The  presence  or  absence  of  bony  matter  in  an 
Dsteo-sarcomatous  tumour  will  probably  depend,  Mr.  C  thinks,  on 
,  the  relative  activity  of  the  secreting  and  absorbing  systems  in  the 
diseased  bone.     He  is  also  of  opinion,  that  the  varieties  w^hich  are 
met  with  in  the  character  and  nature  of  osseous  tumours,  depend 
greatly  on  the  kind  of  constitution  of  the  patient,  whether  that  be 
,healthy,  cachectic,  or  scrofulous.* 


SECTION    IV. DILATATION,     DEFORMATION,    AND    ABSORPTION 

OF  THE  ORBIT,  FROM  PRESSURE. 

When  an  abscess  or  a  tumour  forms  within  any  of  the  osseous 
cavities  of  the  body,  pressure  slowly  dilates  even  the  bones,  thins 
them,  softens  them,  and  forces  them  to  give  way.  The  bones  of 
the  cranium  are  not  exempt  from  these  changes,  and  have  been 

*  Dublin  Hospital  Reports.    Vol.  iv.  p.  554.  Dublin,  1827- 
7 


50 

known  to  allow  a  tumour  of  the  brain  to  protrude  externally.     Di 
Donald  Monro  has  related  a  case  of  this  kind,  in  which  a  tumou 
of  the  brain  protruded  through  the  os  frontis  ;*  and  Mr.  Hunter  ha 
noticed  a  case  so  exactly  similar,  that  it  is  likely  it  was  the  ver 
same  which  was  seen  by  Dr.  Monro.     Mr.  H.  thinks  that  the  tu 
mour  had  probably  formed  in  the  pia  mater.     It  was  oblong,  above 
an  inch  thick,  and  two  or  more  inches  long.     It  was  sunk  nearh  i 
its  whole  length  into  the  brain,  seemingly  by  the  simple  effects  o  j 
pressure,  but  the  outer  end  of  it,  by  pressing  against  the  dura  matei  j 
had  produced  the  entire  absorption  of  this  membrane  at  the  pari 
pressed  upon.     The  same  irritation  had  been  communicated  toth( 
skull,  which  was  also  absorbed  ;  after  which,  the  same  dispositior/ 
was  continued  on  to  the  scalp.     As  these  respective  parts  gave  way. 
the  tumour  was  pushed  farther  and  farther  out,  so  that  its  outer 
end  came  to  be  in  this  new  passage  which  the  absorbents  were 
making  for  it  in  the  scalp,  by  which  it  probably  would  have  been 
discharged  in  time,  if  the  man  had  lived  ;  but  it  was  so  connected 
with  the  vital  parts,  that  the  man  died  before  the  parts  could  relieve 
themselves.     While  all  these  exterior  parts  were  in  a  state  of  ab- 
sorption, the  internal  parts  which  pressed  upon  the  inner  end  of  the 
tumour,  and  which  pressure  was  sufficient  to  push  it  out,  did  not  in 
the  least  ulcerate,  nor  did  the  tumour  itself,  which  was  pressed  upon 
all  sides,  in  the  least  give  way  in  its  substance.     No  matter  was  to 
be  observed  ;  neither  from  the  dura  mater,  the  edge  of  the  bones  of 
the  skull,  nor  that  part  of  the  scalp  which  had  given  way.     The 
general  effect,  however,  was  similar  to  the  progress  of  an  abscess, 
insomuch  that  it  was  on  the  side  nearest  to  the  external  surface  of 
the  body  that  the  irritation  for  absorption  had  taken  placet 

The  process  by  which  an  abscess  or  a  tumour  is  thus  brought  to 
the  surface  of  the  body,  Mr.  Hunter  regarded  as  a  combination  of 
interstitial  and  progressive  absorption — interstitial,  because  parti- 
cles, only  from  the  interstics  of  the  part,  are  for  a  time  removed,  the 
part  still  remaining — progressive,  on  account  of  the  tending  to  the 
surface,  till  at  length  the  surface  gives  way,  and  the  abscess  or  the 
tumour  finishes  its  progress  by  being  exposed  or  evacuated.  By 
the  process  in  question,  the  internal  parts  of  the  body  are  to  a  cer- 
tain extent  protected  from  the  intrusion  of  such  diseases,  and  in 
many  cases  a  cure  is  effected  by  the  discharge  of  the  morbid  accu- 
mulation or  growth.  Hence  Mr.  H.  called  interstitial  and  pro- 
gressive absorption,  the  Natural  iSiirgeon.l 

If,  then,  the  thick  bones  of  the  cranium  are  forced  to  yield,  how 
much  more  readily  will  the  bones  of  the  orbit  suffer  from  the  same 
process,  excited  either  from  within  that  cavity,  or  without  from  the 

*  Medical  Transactions,  Vol.  ii.  p.  353.     London,  1772. 

t  Hunter  on  the  Blood,  Inflammation,  and  Gun-shot  Wounds,  Vol.  ii.  p.  307. 
London,  1812. 
±  Ibid.  Vol.  ii.  p.  287. 


61 

surrounding'  cavities,  the  nostril,  the  frontal,  maxillary,  and  sphe- 
noid sinuses,  or  the  cranium. 

1.  Pressure  on  the  Orbit  from  within  the  Orhit. 

Yarious  causes  within  the  orbit  may,  by  pressure,  produce  dilata- 
tion and  absorption  of  its  walls.  I  have  seen  the  orbit  slowly  en- 
larged by  the  growth  and  pressure  of  a  diseased  lachrymal  gland, 
till  it  was  of  size  sufficient  to  contain  the  fist,  and  at  several  points 
had  given  way.  Effused  blood,  collections  of  matter,  aneurisms, 
I  enlargements  of  the  eyeball,  encysted  and  other  tumours,  are  all 
ki'  capable  of  producing  such  effects. 

If  pressure  from  within  the  orbit  is  sudden,  it  will  in  some  cases 
I  produce  inflammation  of  the  bones,  and  caries  ;  but  if  carried  on 
1  slowly,  perhaps  during  the  course  of  many  years,  dilatation  and 
f  absorption,  without  any  formation  of  matter,  and  even  without  in- 
;flammation,  will  be  the  effect.  It  sometimes  happens,  however, 
[that  after  the  orbit  has  been  slowly  dilated,  and  perhaps  partly  ab- 
[  sorbed  in  consequence  of  the  pressure  of  a  morbid  growth  within  it, 
j  the  tumour  begins  to  inflame  and  form  matter,  and  this  action 
I  spreading  to  the  surrounding  parts  brings  on  caries.  If  it  is  the 
i  roof  of  the  orbit  which  has  become  affected  in  this  way,  the  dura 
j'  mater  inflames  and  throws  out  matter,  the  brain  participates  in  the 
j  disease,  and  death  follows  more  or  less  speedily. 

,.  2.  Pressure  on  the  Orhit  from  the  Nostril. 

The  nostril  communicates  with  the  orbit  by  the  lachrymal  pas- 
sage.    The  OS  unguis  and  os  planum  of  the  ethmoid  form  a  thin 
i  partition  between  these  cavities ;  a  partition,    which,  but  for  the 
i{  instinctive  property  of  the  body  already  referred  to,  by  which  mor- 
bid growths  are  always  forced  towards  the  external  surface,  should 
often  be  broken  through  by  polypus  of  the  nostril.     This  tumour, 
after  filling  the  nostril  in  which  it  has  originated,  dilates  it  at  its 
anterior  opening,  and  presses  the  septum  narium  aside  so  as  to 
amphfy  the  cavity  of  that  nostril  at  the  expense  of  the  other.     It  is 
i  not  in  general  till  the  nostril  is  in  this  way  greatly  dilated,  and  of 
|Course  the  face  much  disfigured,  that  the  polypus    pushes   itself 
iKirough  the  os  unguis,  and  projects,  covered  by  the  inflamed  inte- 
'Jguments,  in  the  situation  of  the  lachrymal  sac.     Previously  to  this, 
1  however,  the  passage  for  the  tears  has  been  obstructed,  and  a  pain- 
I  ful  feeling  of  pressure  experienced  in  the  orbit  and  through  the  head. 
[i  As  the  polypus  advances,  the  orbit  is  still  more  intruded  upon,  the 
eyeball  is  displaced,  vision  is  lost,  and  in  some  cases  even  the  cavi- 
1  ty  of  the  cranium  giving  way,  the  morbid  growth  gains  admittance 
into  contact  with  the  brain. 

Alibert  relates  the  case  of  Louis  Niacre,  aged  22,  who  at  the  age 

![  of  16  became  affected  with  frequent  bleeding  from  the  nose,  which 

returned  upon  the  slightest  touch.     One  day  the  epistaxis  being 

much  more  severe  than  usual,  dossils  of  charpie  were  introduced  at 


52 

the  anterior  opening  of  the  nostrils,  not  by  a  medical  man,  and  per- 
haps not  with  sufficient  caution  and  delicacy.     The  consequence 
was  that  the  mucous  membrane  was  excoriated.     The  patient  felt 
some  slight   pain  ;  but  paid  little  attention  to  this  circumstance, 
being  satisfied  at  seeing  the  bleeding  stopped.     A   year  elapsed, 
when  one  day  having  introduced  his  finger  into  one  of  his  nostrils, 
he  felt  a  small  prominence ;  which,  unluckily,  he  fell  into  the  halnt 
of  rubbing  and  irritating  incessantly,  so  that  in  a  short  time  it  was 
considerably  increased  in  size.     Respiration  became  impeded  ;  the 
air,  in  escaping  by  the  nostrils,  pushing  the  excrescence  forwards 
and  downwards.     The  polypus   was  evidently  making  progress. 
The  inner  angle  of  the  left  eye  swelled,  and  became  red,  tense,  and 
painful.     This  was  attended  with  stillicidium  lachrymarum.     A 
lachrymal  tumour  formed,  in  consequence  no  doubt  of  the  polypus 
compressing  the  passage  for  the  tears  and  displacing  the  os  unguis. 
The  cheek  of  the  same  side  inflamed,  and  presented  to  the  touch 
the  feeling  of  fluctuation.     Alibert  supposes  that  the  fluid  contained 
in  the  larchrymal  tumour,  having  made  its  way  into  the  lower  part 
of  the  nasal  duct,  but  being  hindered  by  the  polypus  from  entering 
the  nostril,  had  flowed  into  the  maxillary  sinus.     Not  merely  the 
cheek,  but  also  the  interior  of  the  iTiouth  w^as  aflfected,  and  the  last 
four  grinding  teeth  of  the  upper  jaw  were  bent  inwards.     At  this 
period,  the  patient  apphed  to  a  surgeon,  who  made  a  deep  incision 
into  the  most  depending  part  of  the  tumour,  and  gave  exit  to  a 
large  quantit}''  of  pus.     The  cheek  fell  in  consequence  of  this,  but 
a  considerable  swelling  continued  wathin  the  mouth.     As  the  poly- 
pus seemed  to  be  increasing  from  day  to  day,  the  surgeon  tied  the 
portion  of  it  which  protruded  from  the  nostril.     After  this,  it  grew 
no   more  in  length ;    but  it   increased  considerably  in  thickness. 
The  prominence  at  the  inner  angle  of  the  eye,  began  to  grow  im- 
mediately after  the  inferior  portion  of  the  polypus  was  tied.     It  soon 
reached  the  size  of  a  walnut.     Its  growth  pushed  the  cartilaginous 
septmn  of  the  nostrils  and  the  vomer  to  one  side  ;  the  ossa  nasi 
were  separated  from  one  another  ;  the  whole  nose  dilated  and  flat- 
tened ;  one  of  the  lateral  portions  of  the  ethmoid  pushed  outwards, 
so  as  to  intrude  upon  the  orbit,  and  force  the  eyeball  forwards  be- 
yond the  level  of  the  eyelids.     The  patient  scarcely  saw  with  thd 
protruded  eye.     Alibert  has  given  a  portrait  of  the  patient  at  thil[ 
period  ;  and  mentions  that  both  eyes,  but  especially  the  left,  seem- 
ed ready  to  start  from  their  sockets  ;  the  left  eyelids  w^ere  inflamed  ; 
and  the  lower  everted,  the  fungous  tumour  which  had  sprouted  up 
through  the  os  unguis,  preventing  it  from  being  applied  to  the  eye- 
ball.    The  left  nostril  was  obstructed  by  the  polypus  :  the  right  by 
the  vomer,  pushed  into  it  by  the  polypus.     The  mouth  was  dis- 
torted, and  its  mucous  membrane  much  thickened.     Bleeding  still 
took  place  from  the  nose  on  the  slightest  eftbrt.     The  patient  felt 
pain  between  the  eyes  ;  but  continued  to  eat  and  sleep.* 

»  Alibert,  Nosologic  Naturelle.  Tome  i.  p.  529.   Paris,  1817. 


53 

The  result  of  this  case  is  not  given  ;  perhaps  it  may  even  admit 
of  doubt,  whether  this  was  really  a  case  of  nasal  polypus,  or  of  fun- 
gus of  the  maxillary  sinus  ;  but  various  other  cases  are  recorded, 
by  which  the  farther  progress  of  neglected  nasal  polypus,  and  its 
fatal  termination,  as  well  as  its  effects  upon  the  orbits,  are  illus- 
trated. 

Mr.  Cooper  mentions,  that  in  April  1817,  a  boy  in  St,  Bartholo- 
mew's Hospital,  12  years  old,  fell  a  victim  to  the  ravages  of  the  larg- 
est and  most  disfiguring  disease  within  the  nose  which  he  ever  had 
had  an  opportunity  of  beholding.  The  tumour  had  expanded  the 
upper  part  of  the  nose  to  an  enormous  size  ;  while  below,  the  left 
nostril  was  immensely  enlarged.  The  distance  between  the  eyes^ 
was  extraordinary,  being  more  than  four  inches.  The  left  eye 
was  affected  with  amaurosis,  brought  on  by  the  pressure  of  (he 
swelling  ;  the  right  retained  to  the  last  the  faculty  of  seeing.  The 
tumour  nearly  covered  the  mouth,  so  that  food  could  be  introduced 
only  with  a  spoon,  and  an  examination  of  the  palate  was  impossi- 
ble. About  a  fortnight  before  death,  the  leg  became  paralytic,  and 
during  the  last  week  of  the  boy's  existence,  an  incontinence  of  the 
urine  and  faeces  prevailed.  On  examination  of  the  head  after  death, 
a  good  deal  of  the  tumour  was  found  to  be  of  a  cartilaginous  con- 
sistence, and,  what  was  most  remarkable,  a  portion  of  it,  as  large 
as  an  orange,  extended  within  the  cranium,  where  it  had  annihi- 
lated the  anterior  lobe  of  the  left  hemisphere  of  the  brain.  Notwith- 
standing this,  the  boy  was  not  comatose,  nor  insensible,  till  a  few 
hours  before  his  decease.  All  the  surrounding  bones  had  been 
more  or  less  absorbed,  and  the  place  where  the  excrescence  first 
grew  could  not  be  determined.* 

In  1817,  I  had  an  opportunity  of  examining  a  skull  in  the  pos- 
session of  Professor  Prochaska,  which  had  suffered  an  extraordinary 
change  in  structure  and  form  from  polypus.  The  patient  was  a 
young  man,  18  years  old  when  he  died.  During  his  apprentice- 
ship to  a  shoemaker,  he  had  been  ill-used  by  his  master,  knocked 
down  by  blows  on  the  head,  and  kicked  by  him  while  on  the  ground, 
in  consequence  of  which  he  began  to  be  affected  with  weakness  of 
sight,  and  prominence  of  the  eyes.  In  1786.  he  was  brought  to 
Prochaska,  then  at  Prague.  Both  eyes  were  amaurotic,  and  pro- 
truding from  the  orbits,  the  bones  both  above  the  orbits,  and  at  the 
sides  of  the  nose  tumified,  and  respiration  through  the  nostrils  ob- 
structed. He  continued  in  this  state  till  1791,  without  pain,  and 
almost  without  any  other  inconvenience  than  the  amaurosis.  Gradu- 
ally, however,  the  eyes  protruded  more  and  more ;  the  face  above 
the  orbits,  at  the  root  of  the  nose,  and  throughout  the  whole  upper 
jaw,  became  enlarged,  as  did  also  the  palate,  which  began  to  pro- 
ject into  the  cavity  of  the  mouth.  Ichorous  discharge  followed  from 
the  nostrils,  with  frequent  and  profuse  bleeding.     For  four  weeks 

*  Cooper  's  Dictionary  of  Practical  Surgery.     Article,  Polypus. 


54 

before  his  death  he  was  confined  to  bed  from  weakness,  breathing- 
not  at  all  through  the  nostrils,  and  with  difficulty  through  the 
mouth  ;  his  mind,  however,  not  affected.  On  the  morning  of  the 
18th  September,  1791,  his  mother  found  him  insensible  ;  and  in 
the  evening  of  that  day,  respiration  through  the  mouth  and  nose 
being  completely  impeded,  he  died.  The  head,  examined  external- 
ly, presented  above  the  eyes  two  tumours  into  which  the  supra-or- 
bitary  arches  had  degenerated,  while  the  root  of  the  nose,  and  the 
upper  jaw  on  each  side,  were  so  much  swollen  that  no  part  of  the 
nose  but  the  point  and  pinnae  was  visible.  On  dissection,  the  right 
nostril  at  its  anterior  part  was  found  greatly  dilated,  the  cartilagin- 
ous septum  being  pushed  to  the  left  side  ;  posteriorly,  the  osseous 
septum  was  destroyed,  and  both  nostrils  were  converted  into  one 
ample  cavity,  filled  by  a  tumour,  remarkable  for  its  spongy  excres- 
cences, and  which  by  its  pressure  had  dilated  and  pushed  down  the 
palate.  On  opening  the  cranium,  the  anterior  and  middle  lobes  of 
the  brain  were  found  to  be  of  an  unnatural  ash  colour,  and  that 
portion  which  lies  upon  the  cribriform  plate  of  the  ethmoid  and  or- 
bitary  processes  of  the  frontal  bone  dissolved,  along  with  the  dura 
mater,  into  a  pulp  of  the  same  colour,  and  in  contact  with  the  tu- 
mour proceeding  from  the  nostrils.  On  account  of  the  morbid 
condition  of  the  brain,  none  of  the  nerves  fiom  the  olfactory  to  the 
auditory  could  be  distinguished.  The  internal  part  of  the  basis  of 
the  skull,  from  the  orbitary  processes  of  the  frontal  to  the  basilar 
process  of  the  occipital  bone  was  tumified  and  softened.  After 
this  examination  was  made,  the  head  was  submitted  to  maceration,, 
which  being  finished,  there  fell  out  from  the  basis  of  the  cranium,  and 
from  the  nostrils,  a  ponderous  mass,  partly  lardy,  partly  cartilagin- 
ous, but  not  at  all  osseous,  which  by  means  of  its  soft  processes  had 
penetrated  into  the  osseous  swellings  above  the  orbits,  filling  all  the 
interstices  of  the  radiating  laminae  into  which  these  swellings  had 
degenerated,  and  emerging  at  these  places  under  the  common  integ- 
uments. The  following  was  the  state  of  the  cranium.  The  orbi- 
tary processes  of  the  fiontal  bone,  the  ethmoid,  the  vomer,  the  tur- 
binated bones,  the  httle  wings  of  the  sphenoid,  and  its  middle  part, 
except  the  anterior  clinoid  processes,  which  adhered  by  osseous'fila- 
ments  to  the  remaining  part  of  the  sella  turcica,  the  anterior  part  of 
the  basilar  process  of  the  occipital  bone,  and  the  apices  of  the  petrous 
portions  of  the  temporal  bones,  as  far  as  the  carotid  canals,  were  so 
completely  consumed,  that  the  vast  cavity  of  (he  nostrils,  along  with 
that  of  the  mouth,  opened  into  the  cavity  of  the  cranium.  Forth 
from  the  cranium  also,  as  well  into  the  compressed  and  deformed 
orbits,  as  into  the  supra-orbitary  swellings  alieady  described,  there 
were  many  larger  and  smaller  openings.  The  superior  maxillary 
bones,  with  their  nasal  processes,  and  the  proper  bones  of  the  nose, 
were  much  expanded,  and  so  thinned  away,  that  they  presented  va- 
rious gaps,  opening  into  the  cavity  of  the  nostrils.  The  palatine 
processes   of  the  superior  maxillary  bones   had  disappeared ;  the 


55 

pterygoid  process  of  the  sphenoid  bone,  on  the  right  side,  had  so 
receded  in  its  superior  part,  that  the  spheno-pnlatine  foramen  much 
enlarged,  opened  into  the  zygomatic  fossa.  The  left  antrum  High- 
morianura  had  disappeared  from  compression,  and  the  right  opened 
backwards  by  a  large  hiatus.* 

3.  Pressure  on  the  Orhit  from  the  Frontal  Sinus. 

If  we  consider  that  when  the  frontal  sinus  is  enlarged  inde- 
pendently of  disease,  it  separates  the  orbitary  plate  of  the  frontal 
bone  into  two  laminae,  as  may  not  unfrequently  be  observed  in  the 
skulls  of  very  old  persons,  it  will  not  appear  strange  that  the  pres- 
sure of  a  diseased  and  dilated  frontal  sinus  should  deform  the 
orbit,  displace  the  eyeball,  destroy  vision,  and  ultimately  disorgan- 
ize the  bones  upon  which  the  pressure  is  exercised. 

The  frontal  sinus,  like  the  maxillary,  is  liable  to  several  differ- 
ent kinds  of  disease,  namely,  1st,  inflammation  of  its  lining  mem- 
brane, ending  in  a  collection  of  matter,  which  may  be  either  thin, 
or  thick  and  curdy  ;  2d,  encysted  tumours,  or  what  some  have 
chosen  to  call  hydatids  ;  3d,  tumours,  more  or  less  solid,  and  which 
are  usually  considered  to  be  of  the  nature  of  fungus  or  polypus. 

1.  Inflammation  of  the  frontal  sinuses,  ending  in  a  collection 
of  matter.  The  frontal  sinus,  on  each  side,  is  lined  by  a  thin  mu- 
cous membrane,  a  continuation  of  that  which  lines  the  nostrils. 
The  two  sinuses  are  separated  by  a  bony  partition,  which  rarely 
runs  in  the  course  of  the  middle  line  ;  so  that,  in  general,  the  one 
sinus  is  larger,  and,  in  many  instances,  much  larger,  than  the 
other.  Each  sinus  communicates  with  the  middle  meatus  of  the 
nostril,  through  the  medium  of  the  anterior  ethmoid  cells.  The  com- 
munication is  narrow  and  circuitous.  Whether  the  diseases  of  the 
frontal  sinuses  are  mainly,  or  frequently,  or  at  all,  to  be  attributed 
to  accidental  closure  of  this  communication,  I  shall  not  pretend  to 
say.  Beer  has  mentioned  sudden  suppression  of  severe  catarrh,  as 
a  cause  of  matter  collecting  within  the  sinuses.  It  is  known,  that 
in  cases  of  wounds  penetrating  into  these  cavities,  their  lining 
membrane  inflames,  and  secretes  a  white  puriform  mucus,  which 
has  sometimes  been  mistaken  for  the  substance  of  the  brain.  Cold, 
and  the  other  causes  which  give  rise  to  the  inflamnnation  of  mu- 
cous surfaces,  m.ay  also  affect  the  lining  membrane  of  these  cavi- 
ties ;  and  in  strumous  constitutions  curdy  pus  will  be  apt  to 
collect  there,  as  it  often  does  in  the  maxillary  sinuses. 

I  may  here  observe,  that  there  appears  to  exist  a  sympathetic 
influence  between  the  Schneiderian  membrane  and  the  retina, 
probably  through  the  medium  of  the  branches  of  the  fifth  pair, 
which  must  lead  us  to  regard  the  diseases  of  the  nostrils,  and  of 

Prochaska  has  given  two  engravings,  exhibiting  a  front  and  a  side  view  of  this 
remarkable  skull,  in  his  Disquisitio  Anatomico-Physiologica  Organismi  Corporis  Hu- 
mani.    Vienna,  1812.  p.  172. 


56 

the  frontal  sinuses,  as  operating-  not  merely  mechanically  upon 
the  orbit,  but  vitally  on  the  organ  of  vision.  Suppression  of  the 
natural  discharge  from  that  membrane,  independently  of  any 
other  alteration,  seems  occasionally  to  be  the  cause  of  amaurosis. 

It  will  scarcely  be  necessary  for  me  to  quote  cases  of  simple 
suppuration  of  the  frontal  sinuses  ;  I  shall  refer  the  reader  to  the 
cases  related  by  Runge*  and  Richter.t  One  of  these  recovered 
after  the  sinus  was  opened  externally  ;  another,  after  bursting  of 
the  matter  into  the  nostril ;  while  a  third  proved  fatal  after  spon- 
taneous discharge  of  the  matter  through  the  external  table  of  the 
frontal  bone,  and  through  the  middle  of  the  upper  eyelid. 

In  the  early  stage  of  inflammation  of  the  frontal  sinuses,  the 
obscurity  of  the  symptoms  will  rarely  permit  any  decided  judg- 
ment to  be  formed  of  the  case,  or  any  active  treatment  to  be 
adoped.  In  ail  the  three  cases  to  which  I  have  referred,  the  dis- 
ease had  advanced  either  to  the  formation  of  a  considerable  pro- 
trusion of  the  outer  wall  of  the  affected  sinus,  or  even  to  the  giving 
way  of  the  cavity,  and  the  evacuation  of  the  contained  matter, 
before  any  suspicion  seems  to  have  been  excited.  Leeches,  and 
other  antiphlogistic  means  would,  of  course,  be  adopted,  were  we 
early  enough  in  being  called  in,  and  did  the  pain,  and  other 
symptoms,  appear  to  indicate  inflammation  of  the  lining  membrane 
of  the  sinus.  Emollient,  and  afterwards  stimulating  vapours, 
drawn  up  into  the  nostrils,  might  be  tried.  Jf  they  should  succeed 
in  exciting  a  considerable  discharge  from  the  nostrils,  this  might 
tend  to  relieve  the  inflamed  membrane  of  the  sinuses. 

In  the  suppurative  stage,  perhaps  counter-irritation  and  a  variety 
of  other  measures,  might  prove  useful. 

The  last  stage,  in  which  the  frontal  bone  becomes  deformed, 
thinned,  softened,  so  that  it  yields  to  external  pressure  like  a  piece 
of  elastic  cartilage,  or  even  perforated  by  absorption,  or  by  caries, 
cannot  be  mistaken  ;  nor  can  there  exist  any  doubt  about  the 
propriety  of  opening  the  sinus,  either  with  a  small  trephine,  or  with 
a  strong  curved  knife,  evacuating  its  contents,  endeavouring  to  im- 
prove the  sto-te  of  its  lining  membrane,  by  lunar  caustic  injections, 
and  the  like,  and  then  allowing  the  parts  to  granulate  and  heal. 

In  one  case,  in  which  Beer  trepanned  the  sinus,  not  merely  was 
that  cavity  restored  completely  to  its  natural  state,  but  the  eyeball 
returned  to  its  proper  place  in  the  orbit,  and  vision  was  recovered. 
In  a  second  case,  in  which  the  external  appearances  were  not 
nearly  so  alarming  as  in  the  former,  after  opening  the  outer  table, 
he  found,  on  examining  cautiously  with  the  probe,  that  the  inner 
table  was  softened,  and  even  drilled  through;  in  this  case  the  e^^e 
was  totally  bhnd.  and  Beer  endeavoured  merely  to  check  the  pro- 

*  Runge  de  Morbis  Sinuum  Ossis  Frontis  et  Maxillae  Superioris ;  in  Haller's 
Disputationes  ChirurgicfE.    Tom.  i.  p.  212.     Lausannse,  1775. 

t  Novi  Commentarii  Societatis  Regies  Gottingensis.  Tom.  iii.  p.  85.  Gottingae- 
1773. 


57 

gress  of  the  disease,  by  inaking  a  counter-opening  through  the 
conjunctiv^a,  above  the  eyeball.  lu  a  third  case,  the  symptoms  were 
decidedly  those  of  a  collection  of  puriform  mucus  in  the  sinus,  but 
the  patient  would  hear  of  no  operation  being  attempted.  Five 
weeks  after  Beer's  first  visit,  the  outer  wall  of  the  sinus  gave  way 
of  itself;  and  in  course  of  two  weeks  more,  the  eye  was  lost,  and  a 
great  portion  of  the  orbit  and  of  the  nose  destroyed  by  caries.  The 
other  eye  remained  completely  amaurotic* 

2.  Encysted  tumours,  or  hydatids,  of  the  frontal  simises. 
Langenbeck  has  given  an  interesting  narrative  of  a  case  of  exoph- 
thalmos from  diseased  frontal  sinus.  He  speaks  of  it  as  a  case  of 
hydatid ;  a  term  much  misapplied  by  the  German  pathologists ; 
Runge  would  have  probably  regarded  it  as  a  cystic  tumour  ;  per- 
haps it  was  nothing  more  than  a  collection  of  thick  matter.  The 
situation  of  the  protrusion  is  one  of  the  most  remarkable  circum- 
stances of  the  case. 

A  ploughboy,  of  20  years  of  age,  11  years  before  his  admission 
into  the  hospital,  had,  while  playing  at  tennis,  received  a  stroke 
with  a  racket  on  the  left  side  of  the  nose,  and  on  the  left  eye,  the 
consequence  of  which  was  a  great  degree  of  swelling,  which,  after 
a  time,  completely  disappeared.  Two  years  afterwards,  he  began 
to  feel  pain  in  the  part,  and  observed  a  protuberance  at  the  inner 
angle  of  the  eye.  When  the  patient  came  to  the  hospital,  Lang- 
enbeck found  the  eyeball  natural  in  form,  the  power  of  vision  not 
affected,  and  the  pupil  lively.  The  eyeball,  however,  was  pressed 
outwards  and  downwards,  by  a  considerable  swelling  at  the  inner 
angle  of  the  eye.  The  swelling  had  exactly  the  appearance  and 
the  situation  of  a  greatly  distended  lachrymal  sac,  but  was  con- 
siderably bigger  than  we  almost  ever  find  the  sac,  even  in  its  state 
of  greatest  enlargement.  That  this  swelling  did  not  consist  in  an 
enlarged  lachrymal  sac,  Langenbeck  concluded  from  his  not  being 
able  to  empty  it  by  pressure,  no  mucus  or  tears  being  evacuated 
from  the  puncta  on  pressure,  and  the  tears  being  duly  conveyed 
into  the  nostril  without  dropping  upon  the  cheek.  The  patient's 
voice  was  similarly  affected  as  that  of  one  with  polypus  in  the  nose. 
The  swelling  communicated  an  obscure  impression  of  fluctuation. 
At  the  inner  side  of  the  swelling,  or  towards  the  nose,  it  was 
bounded  by  a  sharp  edge  of  bone,  which  was  felt  exactly  where  the 
nasal  process  of  the  upper  maxillary  bone  rises  by  the  inner  side  of 
the  orl3it.  As  the  surface  of  the  swelling  was  not  covered  by  any 
layer  of  bone,  but  felt  soft  and  fluctuating,  it  was  not  easy  to  form 
a  proper  judgment  regarding  its  seat,  and  one  might  have  readily 
fallen  into  the  error  of  supposing  it  to  be  an  enlarged  lachrymal 
sac.  Against  such  a  supposition,  no  doubt,  there  was  the  remark- 
able displacement  of  the  eye  outwards  and  downwards.  As  the 
swelling  also  extended  from  the  inner  angle  upwards  and  towards 

*  Lehre  von  den  Augenkrankheiten,  Vol.  ii.  p.  570.     Wien,  1817. 

8 


58 

the  frontal  sinus,  Langenbeck  concladed  that  that  cavity  was  the 
seat  of  the  disease.  Six  months  before,  he  had  extracted  a  large 
hydatid  from  tlie  frontal  sinus  of  a  young  woman,  in  whom  the 
external  table  had  been  very  considerably  pushed  forwards,  and  the 
orbitary  process  of  the  frontal  bone  so  much  depressed,  that  the 
eyeball  lay  opposite  to  the  point  of  the  nose.  In  this  case  he  had 
perforated  the  external  table,  and  extracted  what  he  teriiis  the 
hydatid  ;  after  which  the  sinus  appeared  2^  inches  deep.  He  was 
led  then  to  suspect  a  similar  disease  in  the  ploughboy;  that  the 
swelling  was  contained  in  the  frontal  sinus,  whence  it  had  pressed 
itself  downwards  into  the  nostril,  and  at  the  same  time  had  pressed 
the  inner  wall  of  the  orbit  outwards.*  He  proceeded  to  operate  in 
the  following  manner.  He  made  an  incision  from  above  down- 
wards, close  to  the  sharp  edge  of  bone  which  was  felt  at  the  inner 
side  of  the  swelling,  and  in  such  a  way  as  to  avoid  both  the  lachry- 
mal sac  and  lachrymal  canals.  After  the  soft  parts  were  suffi- 
ciently divided,  a  white  glistening  sac  came  into  view.  On  touch- 
ing this  with  the  finger,  it  was  evident  that  it  contained  a  soft  mass. 
He  separated  the  swelling  as  much  as  possible ;  but  as  he  found 
that  it  extended  deep  into  the  nostril,  he  opened  it,  whereupon  there 
issued  from  it  a  greyish  white  tenacious  substance.  He  cut  away 
with  the  scissors  as  much  as  he  could  of  the  sac,  and  introduced 
his  finger  into  its  cavity.  Its  depth  amounted  to  3  inches.  With 
the  point  of  his  finger  he  reached  as  far  as  the  floor  of  the  nostril. 
He  could  not  reach  the  orbit,  nor  touch  the  eyeball.  He  felt  from 
the  diseased  cavity  the  inner  wall  of  the  orbit,  formed  by  the  os 
planum  of  the  ethmoid,  a  part  of  the  orbitary  plate  of  the  frontal, 
and  the  os  unguis.  This  wall  of  the  orbit,  along  with  the  lachry- 
mal sac,  and  nasal  duct,  was  pressed  outwards ;  hence  arose  the 
displacement  of  the  eyeball,  while  the  passage  of  the  tears  into  the 
nose  continued  uninterrupted.  Langenbeck  introduced  his  forefinger 
up  into  the  frontal  sinus.  He  decided,  therefore,  that  the  disease 
had  originated  there,  and  had  descended  by  the  side  of  the  nostril. 
He  could  now  see  into  a  large  cavity,  filled  with  a  grayish  white 
tenacious  mass,  which  he  removed  witli  his  finger  and  a  pair  of 
forceps.  This  substance  was  contained  in  a  shut  sac,  distinct  from 
the  mucous  membrane  of  the  sinus ;  and  had  it  not  been  so,  he 
thinks  the  substance  in  question  would  have  made  its  way  into  the 
nostril.  As  has  already  been  mentioned,  the  swelling  was  not 
covered  by  bone  at  the  inner  angle  of  the  eye.  It  must  therefore, 
he  thinks,  have  made  its  way  either  between  the  os  unguis  and 
nasal  process  of  the  superior  maxillary  bone,  or  it  must  have  pro- 
duced the  absorption  of  the  latter.  This  is  the  more  probable  con- 
jecture, as  the  edge  of  the  nasal  process  felt  so  sharp.  The  tena- 
cious substance,  which  was  extracted,  was  enough  to  fill  a  tea  cup.t 

*  Outwards,  from  the  middle  line  of  the  bod^'.  Langenbeck  says  inwards,  but  he 
must  mean  inwards  in  reference  to  the  axis  of  the  orbit. 

t  Langenbeck's  Neue  Bibliothek  fur  die  Chirurgie  und  Ophthalmologie.  Vol.  ii. 
p.  245.    Hanover,  1819. 


69 

Mr.  Keate  has  recorded  a  case  of  what  he  terms  an  enormous 
collection  of  hydatids,  between  the  two  tables  of  the  frontal  bone. 
He  appears  to  be  of  opinion  that  they  were  not  contained  within 
the  sinuses.  I  might  therefore  be  blamed  for  quoting  the  case,  in- 
teresting as  it  is,  did  I  not  consider  the  evidence  adduced  insufficient 
to  prove  that  the  sinuses  were  imconnected  with  the  disease  ;  and 
did  I  not  conceive  these  cavities  liable  to  be  affected  in  the  very 
manner  described  by  Mr.  K.  The  patient,  a  girl  of  18  years  of 
age,  consulted  him  about  a  large  tumour,  chiefly  over  the  left  orbit, 
but  extending  partially  above  the  inner  angle  of  the  right  orbit  also, 
and  occupying  the  greater  part  of  the  left  portion  of  the  frontal  bone. 
She  had  first  discovered  a  small  hard  tumour  about  the  size  of  a 
hazel  nut,  6  years  before,  towards  the  lower  part  of  the  bone  over 
the  left  brow,  which  had  at  first  increased  slowl}^,  but  for  3  years 
more  rapidly,  so  that  it  had  attained  the  size  and  shape  of  fths  of 
a  large  orange.  She  had  felt  uneasiness  externally  from  the  com- 
mencement of  the  swelUng,  attended  with  a  sense  of  throbbing 
round  its  base ;  but  till  a  short  time  before  consulting  Mr.  K.,  there 
had  been  no  symptoms  of  internal  pressure.  She  then  felt,  how- 
ever, intense  headachs,  occasional  vertigo,  dimness  of  sight,  nausea, 
and  tinnitus  aurium.  Mr.  K.  concluded  that  the  disease  lay  be- 
tween the  two  tables  of  the  frontal  bone,  the  external  table  being 
pushed  forward  so  as  to  cause  the  convex  protuberance,  while  the 
internal  was  probably  depressed  and  was  giving  rise  to  the  above- 
mentioned  urgent  symptoms.  By  a  crucial  incision  through  the 
integuments,  Mr.  K.  exposed  the  bony  covering  of  the  tumour.  It 
appeared  extremely  thin  and  vascular.  He  had  divided  about  one- 
third  of  the  circumference  of  the  base  of  the  tumour,  with  the  met- 
acarpal saw,  when  one  of  the  assistants  thought  he  perceived, 
through  the  groove  made  by  the  saw,  a  pulsation,  as  if  of  the  ves- 
sels of  the  dura  mater.  This  led  Mr.  K.  to  detach  a  portion  of  the 
bones,  in  order  to  ascertain  the  nature  of  the  tumour,  before  he 
proceeded  farther  in  sawing  through  the  base.  This  was  effected 
by  the  elevator,  when  a  thin  transparent  membrane  was  discovered 
closely  lining  the  bony  case  ;  but  in  breaking  off  this  small  piece 
of  bone,  the  cyst  was  ruptured,  and  its  contents,  a  thin  colourless 
fluid,  escaped  ;  the  cyst  at  the  same  time  collapsing  into  the  cavity. 
On  examining  the  cavity  with  the  finger,  it  presented  an  irregular 
surface,  or  floor,  hned  by  the  membrane  above  described,  but  evi- 
dently depressed  below  the  proper  level  of  the  internal  table.  No 
pulsation  was  now  perceptible,  and  no  orifice,  leading  through  the 
internal  table  and  communicating  with  the  meninges,  was  discov- 
erable. Some  more  small  pieces  of  bone  were  then  removed,  but 
the  patient  had  by  this  time  become  so  exhausted  that  it  was  thought 
prudent  to  discontinue  the  operation,  leaving  the  remainder  of  the 
bony  case  to  be  subsequently  detached,  or  destroyed.  Severe  pain, 
and  violent  fever  followed  the  operation.  The  cavity  of  the  tu- 
mour was  at  first  tightly  filled  with  coagula,  which  after  a  time 


60  I 

separated,  and  the  wound  discharged  freely.  Pieces  of  bones  were 
removed  from  daj^  to  day,  and  kali  puram  was  occasionally  applied 
to  promote  exfoliation.  At  length,  ou  the  left  side  of  tlie  wound, 
where  the  surface  had  healed  very  quickly  after  the  operation,  a 
small  puffy  tumour  appeared,  which  Mr.  K.  considered  to  be  a  part 
of  the  original  cyst  filling  again.  An  attack  of  fever  and  erysipe- 
las coming  on,  the  kali  purum  was  discontinued,  and  the  wound 
allowed  to  heal.  The  puffy  swelhng  above-mentioned  gradually 
increased  in  size  to  nearly  that  of  the  original  tumour.  Whenever 
it  became  tense,  the  membrane  and  thin  cuticle  gave  way,  and  the 
contents  (the  same  sort  of  limpid  fluid  that  was  originally  dis- 
charged) were  evacuated.  The  cyst  then  collapsed,  the  opening 
healed,  the  tumour  filled  again,  and  the  same  process  was  repeated. 
About  10  months  after  the  first  operation,  the  cyst  had  increased  to 
a  great  extent,  and  protruded  beyond  the  limits  of  its  former  bony 
covering ;  even  the  circumference  of  the  bony  base  was  evidently 
enlarged.  Mr.  K.  punctured  the  cyst,  and  about  4  oz.  of  a  clear 
straw-coloured  fluid  escaped  :  the  cyst  collapsed,  but  under  it  there 
appeared  to  be  a  soft  tumour  filling  the  cavity  within  the  bony 
prominence.  When  the  cyst  filled  again,  he  applied  kali  purura  to 
its  tense  surface  ;  four  days  after  which,  nearly  4  oz.  were  evacua- 
ted from  it,  through  the  opening  made  by  the  caustic,  and  a  mem- 
branous bag  came  away  with  the  discharge.  Mr.  K.  considered 
this  bag  to  be  a  hydatid.  He  repeated  the  kali  purum  till  the  whole 
covering  of  the  tumour  was  destroyed.  This  disclosed  a  number  of 
separate  cysts  lining  the  cavit}".  To  these  the  caustic  was  freely 
applied.  They  were  slowly  destroyed,  and  rapidly  reproduced. 
Nitric  acid,  sulphas  cupri,  and  the  actual  cautery  heated  212°,  vvere 
tried  without  any  better  effect  than  the  kali  purum.  An  arsenical 
caustic  was  next  employed,  and  produced  a  very  large  and  deep 
slough,  which  appeared  to  remove  the  greater  part  of  the  remaining 
hydatids.  There  were  still,  however,  imperfect  cysts,  particularly 
at  the  outer  part  of  the  tumour  near  the  left  temple,  and  at  the 
upper  part  of  its  base,  to  which  Mr.  K.  reapplied  the  arsenic.  Seven 
days  after  this  application,  a  slough  separated  from  nearl}'^  the  whole 
internal  surface  of  the  cavity,  leaving  only  two  distinct  cysts  visible 
at  the  lower  and  anterior  part,  just  over  each  frontal  sinus.  Mr.  K. 
passed  a  probe  into  each  ;  the  cavity  was  trifling,  and  did  not  ap- 
pear to  communicate  with  the  sinus  :  but  on  pressing  the  bottom  of 
the  left  cavity,  acute  pain  w^as  produced  in  the  eye  of  that  side. 
For  some  days  after  this,  the  patient  suffered  severe  pain  in  the 
bead,  a  sense  of  tightness  across  the  forehead  and  pain  in  the 
globes  of  the  eyes.  These  symptoms  were  removed  by  the  free 
use  of  leeches.  She  had  suffered  so  much  from  the  repeated  and 
severe  escharotic  applications,  that  Mr.  K.  now  resolved  again  to 
expose  the  bone  and  to  remove  the  whole  of  the  remaining  emi- 
nence by  the  saw.  This  was  accordingly  done.  The  largest  di- 
ameter of  the  basis  cut  through  by  the  saw  was  4J  inches :  the 


61 

smallest,  4  inches.  In  the  very  hard  and  compact  bony  substance 
forming  the  base  of  the  tumour,  were  found  5  or  6  cells  containing 
h3a1atid  cysts.  These  were  carefully  removed.  The  original  large 
aav'ity,  which  had  formed  the  centre  and  greater  mass  of  the  tu- 
mour, from  whence  there  had  been  (to  use  Mr.  K's  expression)  such 
i  rapid  and  inveterate  growth  of  hydatids,  was  also  denuded  of  its 
:ysts  and  granulations,  and  the  inner  table  of  the  cranium  entirely 
exposed.  Lint,  impregnated  with  a  strong  solution  of  co[)per,  was 
applied  to  the  whole  of  the  denuded  surface.  Granulations  rap- 
idly filled  up  the  exposed  cavity ;  till  an  inflammatory  attack  in 
,he  chest,  requiring  repeated  blood-letting,  appeared  to  check  their 
progress.  After  this,  some  small  exfoliations  took  place  ;  and  as 
aer  health  and  strength  improved,  the  wound  contracted,  and  ulti- 
mately healed  completely ."* 

3.  Polypus  of  the  frontal  si7iuses.  I  know  of  no  case  upon 
•ecord,  in  which  polypus  was  found  in  either  of  the  frontal  sinuses, 
kvithout  the  same  disease  existing  in  the  neighbouring  cavities  at 
,he  same  time.  It  is,  however,  quite  conceivable  that  a  polypus 
might  occupy  one  or  other  of  the  frontal  sinuses,  without  any  tu- 
mour of  the  same  sort  existing  in  the  nostrils,  or  maxillary  sinuses ; 
md  that  slowly  dilating  the  cavity  in  which  it  took  its  origin,  it 
might  displace  the  eyeball,  and  extenuate  and  soften  the  external 
able  of  the  frontal  bone.  Under  such  circumstances,  the  sinus 
should  be  opened ;  and  as  polypus  generally  arises,  by  a  narrow 
leck,  from  the  mucous  membrane,  which  gives  it  birth,  the  tumour 
might  be  extirpated  with  success. 

In  172-5,  there  died  at  the  HSpital  de  la  Chariti,  in  Paris,  a 
/oung  man  of  17  or  18  years  of  age,  who  consequent  to  his  having 
lad  sraall-pox,  and  for  the  space  of  three  j'ears,  had  been  alfected 
,vith  polypus.  There  were  seven  of  them  altogether  :  in  the  nose, 
hroat,  maxillary,  and  frontal  sinuses.  His  appearance  was  hideous  ; 
lis  face  enormously  enlarged ;  his  nose  spread  out  to  the  usual 
ividth  of  the  malar  bone  ;  and  the  upper  maxillary  bones  greatly 
lilated.  He  had  a  very  considei"able  protuberance  at  the  root  of  the 
lose ;  his  eyes  were  almost  entirely  protruded  from  the  orbits  ;  the 
iistance  between  them  was  at  least  thrice  the  natural  distance  ;  and 
he  tears  ran  over  the  cheeks,  mixed  with  pus  from  tv/o  iachry- 
iial  fistulee.  The  palate  was  so  much  depressed  that  it  lay  upon 
he  tongue ;  the  lower  jaw  was  not  changed  in  size  or  form,  but  it 
vvas  continually  depressed,  so  that  the  sahva  flowed  uninterruptedly, 
it  the  entrance  to  the  nostrils,  two  polypi  were  seen,  which  com- 
iletely  filled  these  cavities  ;  as  was  pioven  by  introducing  a  flexible 
3robe,  which  could  be  passed  around  each  of  the  polypi,  without 
meeting  with  any  obstacle.  On  dissection,  the  one  superior  max- 
llary  bone  was  found  to  be  at  its  middle  as  thin  as  the  skin  of  an 
Miion  ;  while  the  other  had  already  given  way,  so  as  to  bring  into 

*  Medico-Chirurgical  TransatetionSj  Vol.  x.p.  278.     London,  1819* 


62  ] 

view  the  thia  and  polished  membrane  enveloping  a  polypus,  about 
2  inches  in  diameter,  reddish  and  very  elastic,  loose  at  all  points 
except  towards  the  nostril,  where  it  was  attached  by  a  slender  ped- 
icle. The  two  frontal  sinuses  were  converted  into  a  single  cavity, 
occupied  by  two  polypi  which,  united,  might  have  equalled  the  bulk 
of  the  maxillary  polypus  just  mentioned.  Each  of  them  was  at- 
tached by  a  slender  pedicle,  close  to  the  excretory  passages  from  the 
sinuses.  The  lining  membrane  of  these  cavities  was  thickened. 
The  orbits  were  found  to  be  diminished  in  size  by  the  intrusion  of 
the  polypi ;  the  eyeballs  consequentl}^  displaced  ;  the  ossa  ungues 
completely  separated  from  the  other  bones  of  the  orbits,  and  so  ! 
pressed  upon  as  to  have  become  convex  instead  of  concave  towards 
the  cavities  of  the  orbits  ;  and  the  bones  of  the  nose  separated  from 
each  other,  to  the  extent  of  several  lines.* 

4.  Pressure  on  the  Orbit  fro'in  the  Maxillary  Sinus. 

The  diseases  of  the  maxillary  sinus  are  upon  the  whole  analo- 
gous to  those  of  the  frontal  sinus.  They  are  more  frequent,  more* 
variable,  and  generally  more  easily  recognised.  They  dilate  the 
cavity  of  the  sinus,  thin  by  pressure  the  bones  which  form  its  walls, 
and  force  them  at  last  to  give  way.  They  disfigure  the  face,  dis- 
place the  eyeball,  and  if  neglected  may  ultimately  prove  fatal. 

1.  Collections  of  quucus  or  of  pus  within  the  maxillary  sinus. 
A  thin  continuation  of  the  Schneiderian  membrane  passes  from  the 
upper  part  of  the  middle  meatus  of  the  nostril,  through  a  narrow 
aperture,  into  the  maxillary  sinus,  and  forms  its  lining  membrane. 
The  fluid  secreted  by  this  membrane  is  apt  to  accumulate,  consti- 
tuting what  some  have  called  dropsy  of  the  sinus  ;  in  other  cases, 
this  cavity  is  filled  with  thin  puriform  mucus,  or  with  thick 
curdy  pus.  Obstruction  of  the  communication  between  the  sinus 
and  the  nostril,  cold,  blows,  affections  of  the  teeth,  small-pox,  and 
various  other  causes,  have  been  mentioned  as  giving  rise  to  these 
diseased  accumulations,  which  have  often  been  known  to  increase 
so  much  as  to  elevate  the  floor  of  the  orbit,  and  force  the  eyeball 
forwards  from  its  place,  as  well  as  to  dilate  and  even  perforate  the 
outer  wall  of  the  sinus. 

For  an  example  of  apparently  simple  accumulation  of  mucus 
within  the  maxillary  sinus,  I  may  refer  to  a  case  which  occurred  to 
M.  Dubois.  The  patient,  when  a  boy  of  7  years  of  age,  was  ob- 
served by  his  parents  to  have  a  hard  round  tumour,  about  the  size 
of  a  filbert,  near  the  root  of  the  nasal  process  of  the  left  upper  max- 
illary bone.  It  gave  no  pain,  and  did  not  appear  to  be  increasing. 
A  blow,  however,  which  he  received  about  a  year  after  by  a  fall, 
excited  this  tumour  to  grow,  which  it  did  by  almost  insensible  de- 
grees till  he  was  15.  It  then  began  to  enlarge  more  evidently,  and  to 
cause  slight  pain.     By  the  time  when  he  was  18,  it  was  so  consid- 

*  Leviet,  Observations  sur  la  Cure  de  plueieurs  PolypeSj  p.  235.    Paris,  1749. 


63 

arable  in  size  as  to  raise  the  floor  of  the  orbit,  so  that  the  eye  was 
pressed  upwards,  and  appeared  less  than  the  other,  on  account  of 
the  limited  motion  of  the  lids.  The  palate  was  depressed,  so  tliat 
it  formed  a  swelling  of  about  the  size  of  an  egg  divided  longitudi- 
nally ;  the  nostril  was  almost  completely  closed,  and  the  nose  was 
twisted  to  the  right.  The  cheek  was  prominent ;  and  the  skin 
below  the  lower  eyelid,  and  covering  the  upper  part  of  the  tumour, 
was  of  a  livid  colour,  and  seemed  ready  to  give  way.  The  upper 
lip  was  pushed  upwards,  and  the  whole  length  of  the  gums  on  the 
left  side  had  advanced  beyond  the  level  of  those  of  the  right. 
Breathing,  speech,  mastication,  and  sleep,  were  impeded.  Sabatier, 
Pelletan,  and  Boyer,  being  called  into  consultation,  the  unanimous 
opinion  appears  to  have  been  that  this  was  a  case  of  fungus  of  the 
maxillary  sinus,  requiring  an  operation.  So  much  thinned  was  the 
bone  behind  the  upper  lip,  that  Dubois  felt  there  a  degree  of  fluc- 
tuation, and  proceeded  to  open  the  sinus  at  that  place,  expecting 
merely  to  give  issue  to  a  small  quantity  of  ichorous  fluid,  and  then 
to  encounter  the  fungous  tumour.  The  opening,  however,  allowed 
a  very  considerable  quantity  of  a  ropy  substance  to  escape,  similar 
to  what  is  found  in  ranula.  The  probe  being  passed  into  the 
opening,  entered  evidently  a  large  cavity,  quite  free  of  any  kind 
of  fiingous  or  polypous  growth.  It  is  probable  that  the  opening 
made  at  this  first  operation,  if  kept  from  closing,  would  have 
served  for  the  complete  cure  of  the  disease ;  but  Dubois  appears 
to  have  thought  differently,  and  proceeded  5  days  afterwards  to  ex- 
tract 3  teeth,  and  to  remove  the  corresponding  portion  of  the  al- 
veolar process.  This  enabled  him,  on  placing  the  patient  in  a 
favourable  light,  to  see  the  whole  interior  of  the  dilated  sinus,  at 
the  upper  part  of  which,  and  near  to  the  edge  of  the  orbit,  he  dis- 
covered a  canine  tooth,  which  he  extracted.  After  this,  the  cavity 
grfidually  shrunk ;  the  tumour  of  the  cheek,  that  of  the  palate, 
and  the  displacement  of  the  nose,  continued  for  some  time ;  but 
after  17  months,  no  deformity  existed.* 

A  collection  of  pus  within  the  maxillary  sinus,  whether  produced 
in  consequence  of  primary  inflammation  of  its  lining  membrane,  or 
of  inflammation  excited  by  diseased  teeth,  which  is  more  generally 
the  case,  is  not  unfrequently  evacuated  in  part  through  the  opening 
of  the  sinus  into  the  nostril ;  much  oftener,  however,  that  opening 
appears  to  be  obstructed,  so  that  the  pus  collects  and  distends  the 
sinus,  producing  a  series  of  symptoms  similar  to  those  which  ex- 
isted in  the  case  of  simple  mucocele  just  quoted.  Some  years  ago, 
I  had  under  my  care  a  gentleman,  in  whom  the  left  maxillary  si- 
nus was  affected  with  this  disease,  to  such  a  degree  that  the  face 
was  strikingly  deformed,  the  bone  absorbed  at  the  most  prominent 
part  of  the  cheek,  and  the  eye  beginning  to  be  displaced.  I  directed 
the  second  molaris,  which  was  in  a  decayed  state,  to  be  removed  ; 

*  Boyer,  Traite  des  Maladies  Chirurgicales.     Tome  vi.  p.  140.     Paris,  1818. 


64 

and  through  the  alveohis,  I  perforated  the  sinus  so  as  to  give  exit 
to  a  considerable  quantity  of  purulent  fluid.  1  then  pushed  up  a 
lachrj'niiil  style  into  the  opening,  removing  it  every  day,  and  in- 
jecting the  sinus  with  tepid  water.  Under  this  treatment  the  se- 
cretion of  matter  ceased,  and  the  sinus  shrunk  to  its  natural  size. 

In  neglected  cases  of  suppuration  within  the  maxillary  sinus, 
various  parts  of  its  walls  are  apt  to  be  absorbed  in  consequence  of 
the  pressure  of  the  accumulated  pus,  or  rendered  carious  from  ex- 
cited inflammation.  The  floor  of  the  orbit  sometimes  suffers  these 
changes,  the  matter  issuing  from  the  sinus  infiltrates  behind  the 
lower  eyelidj  the  eyelid  swells  and  inflames,  and  at  length  there 
is  formed  through  it  a  fistulous  opening,  by  which  matter  is  from 
day  to  day  discharged.  Perhaps  the  patient  is  brought  to  us  in 
this  state,  when  on  passing  a  probe  along  the  fistula,  we  readily 
ascertain  that  it  enters  a  diseased  maxillary  sinus.  In  a  case  of 
this  sort,  in  w^iich  the  e3^e  was  already  lost  and  the  floor  of  the  or- 
bit fistulous,  Bertrandi,  having  introduced  the  probe  along  the  fistula 
into  the  maxillary  sinus,  directed  it  as  perpendicularly  as  he  could 
against  the  infetioi"  wall  of  that  cavity,  and  while  with  two  fingers 
of  his  left  hand  he  pressed  against  the  roof  of  the  mouth,  he  with 
the  probe  perforated  the  alveolar  process  from  above,  l^etween  the 
last  two  molares.  After  this  opei'ation,  the  pus  ceased  to  flow  by 
the  flstula  of  the  orbit,  and  the  patient  recovered.*  This  mode  of 
operating  may  be  adopted,  when  the  jaws,  as  is  sometimes  the  case, 
cannot  be  sufficiently  separated  to  permit  a  similar  opening  into  the 
sinus  to  be  made  from  below.  Wherever  the  opening  is  made,, 
whether  at  the  fossa  canina,  or  through  one  of  the  alveoh,  it  ought 
to  be  kept  patent,  either  by  a  dossil  of  lint,  or  by  a  lachr}'mal 
style,  which  is  to  be  withdrawn  daily,  and  the  sinus  injected  either 
with  water  or  a  weak  solution  of  nitras  argenli. 

2.  Polypus  or  fungus  of  the  maxillary  sinus.  I  cannot 
better  illustrate  the  effects  produced  on  the  orbit  by  polypus  or  fun- 
gus of  the  maxillary  sinus,  than  by  relating  the  case  of  James 
M'Culloch,  aged  53,  who  became  a  patient,  under  m}^  care,  at  the 
Eye  Infirmary,  in  February  1S28.  He  stated  that  he  had  been 
sensible  of  a  stuffing  of  the  right  nostril  for  some  years  ;  that  6 
months  before  his  admission,  he  had  been  attacked  with  supra-or- 
bital pain,  darting  towards  the  right  side  of  his  head  :  and  a  short 
time  after  this,  with  pain  in  the  region  of  the  right  maxillary  sinus, 
stretching  towards  the  floor  of  the  orbit,  and  increased  when  he 
opened  his  mouth.  This  was  soon  followed  by  stillicidium  lach- 
rymarum.  a  soft  elastic  sweUing,  in  the  situation  of  the  right  lach- 
rymal sac.  and  protrusion  of  the  eyeball  forwards,  outwards,  and 
upwards,  from  the  orbit.  He  complained  of  a  want  of  the  sense 
of  taste  in  the  right  side  of  his  mouth,  and  want  of  sleep  from  the 
pain  above  the  eye.     On  examining  the  palate,  it  was  found  to  be 

*  Boyer,  Traite  des  Maladies  Chirurgicales.    Tom.  vi.  p.  153.     Paris,  1818. 


65 

yielding  and  elastic  under  the  light  maxillary  sinus.  For  several 
weeks,  the  vision  had  been  double,  in  consequence  of  the  misplaced 
state  of  the  right  eye.  The  conjunctiva  was  inflamed,  the  eye- 
lids adherent  in  the  morning,  and  in  consequence  of  the  exposed 
state  of  the  protruded  eye,  a  small  ulcer  existed  at  the  lower  edge 
of  the  cornea.  The  right  nostril  was  found  to  be  filled  by  a  poly- 
pous excrescence,  of  a  white  colour,  and  medullary  texture,  which 
bled  profusely  on  being  touched. 

After  clearing  away  this  substance  with  the  polypus-forceps,  a 
carious  opening,  sufficient  to  admit  the  end  of  the  little  finger, 
was  found  to  exist  between  the  nostril  and  the  maxillary  sinus. 
With  the  finger,  introduced  through  this  opening,  it  was  ascer- 
tained that  the  sinus  was  completely  stuffed  with  the  same  kind 
of  polypous  excrescence  which  had  occupied  the  nostril.  The 
clearing  of  the  nostril  was  performed  on  the  19th  ;  and  it  is  re- 
markable, that  this  had  so  much  reheved  the  pressure  on  the  orbit, 
that  5  days  after,  when  I  proceeded  to  open  the  maxillary  sinus, 
the  ulcer  of  the  cornea  was  already  cicatrized,  evidently  in  conse- 
quence of  the  eyeball  having  retreated  somewhat  into  the  orbit,  so 
as  to  allow  it  to  be  better  defended  by  the  lids.  On  the  24th,  I 
made  an  incision,  obhque  in  its  direction  from  above  downwards, 
and  from  without  inwards,  through  the  cheek,  down  to  the  bone, 
with  the  intention  of  opening  the  sinus,  and  removing  its  contents. 
1  found,  however,  that  the  polypus  had  ahead}'  produced  absorp- 
tion of  the  outer  wall  of  the  sinus,  to  the  extent  of  half  an  inch 
in  diameter.  Through  this  opening,  the  polypus  was  broken 
down  and  extracted.  The  bony  parietes  of  the  sinus  felt  through- 
out diseased  ;  its  nasal  side  much  disorganized  ;  the  os  unguis 
gone  ;  the  orbital  side,  and  indeed  the  whole  circumference  of  the 
sinus  denuded  of  its  lining  membrane.  A  long  dossil  of  lint  was 
introduced  into  the  sinus.  In  a  few  days,  a  profuse  secretion  of 
white  foetid  matter  flowed  from  the  whole  of  the  internal  surface  of 
the  sinus,  on  removing  the  dossil  of  lint.  By  the  4th  of  March, 
the  nose  and  lachrymal  region  were  much  more  natural  in  their 
appearance,  and  the  e3'^e  more  in  its  place.  A  solution  of  chloride 
of  lime,  (  9  i.  to  ibii.)  was  daily  injected  into  the  sinus,  wnth  the 
view  of  correcting  the  foetor  of  the  discharge.  The  long  dosssil  of 
Unt  was  carefully  introduced,  so  as  to  fill  the  cavity  completely. 
By  the  9th,  all  pain  had  ceased,  the  eye  was  still  more  in  its 
place,  the  vision  improved,  and  the  shape  of  the  face  much  more 
natural.  The  discharge  had  lost  its  foetor,  and  was  less  in  quan- 
tity. By  the  18th,  the  double  vision  was  gone.  By  the  27th 
April,  there  was  very  little  discharge,  and  the  vision  was  much 
improved.  On  the  5th  of  August,  the  report  runs  thus  ; — General 
health  and  local  symptoms  go  on  improving — On  pressing  the 
site  of  the  lachrymal  sac,  thick  white  matter  issues  from  the 
lower  punctum,  but  is  diminishing  under  the  use  of  an  injection  of 
the  nitras  argenti  solution — Antrum  seems  contracting,  and  dis- 
n 


66 

charges  ver}''  little — Water  injected  by  the  opening,  flows  out  hy 
the  nostril.  On  the  whole,  this  case  proved  much  more  satisfactory 
than,  fr(nii  the  very  disoiganized  state  of  the  sinus,  I  had  expected. 
Vision  and  life  were  saved  by  the  operation.  More  than  a  yeai 
after,  he  was  in  good  health,  the  wound  much  contracted,  the 
sinus  still  kept  open  with  a  bent  wooden  style,  and  no  appearance 
of  any  tendency  to  reproduction  of  the  polypus. 

The  sinus  might  have  been  cleared,  in  this  case,  without 
making  any  incision  through  the  integuments,  namely,  by  detach- 
ing the  cheek  from  the  upper  maxillary  bone ;  but  in  this  way 
the  discharge  would  of  course  have  flowed  into  the  mouth,  which 
would  have  been  very  disagreeable  to  the  patient,  and  he  would 
have  been  exposed  to  foreign  substances  entering  the  sinus, 
When  we  are  very  anxious  about  the  personal  appearance  of  the 
patient,  we  will  perhaps  prefer  this  mode  of  operating  ;  but  when 
that  is  less  an  object  than  a  ready,  effectual,  and  even  less  disa- 
greeable method  of  getting  rid  of  the  disease,  the  incision  through 
the  cheek  will  be  adopted.  The  method  of  operating  adopted  bj 
Desault,  in  fungus  of  the  maxillary  sinus,  consisted,  not  merely  in 
opening  that  cavity,  after  detaching  the  cheek  from  the  bone,  bul 
in  removing,  with  the  gouge  and  mallet,  a  considerable  portion  ol 
the  alveolar  process.*  I  should  regard  this  as  unnecessary. 
Through  the  mouth,  it  may  be  somewhat  difficult  sufficiently  tc 
lay  open  the  sinus  ;  but  by  cutting  through  the  cheek,  the  bone 
may  be  so  completely  exposed,  and  an  opening  made  of  such  a 
size  into  the  sinus,  as  shall  easily  permit  the  diseased  mass  to  be 
removed. 

In  the  case  which  1  have  rekted,  the  bleeding  w^as  easily  re- 
strained ;  but  in  other  cases,  profuse  haemorrhage  has  followed  the 
cutting  or  tearing  away  of  the  tumour,  so  as  to  demand  the  appli- 
cation of  the  actual  cautery. 

Mr.  Howship  has  illustrated,  by  a  beautiful  engraving,  the  great 
extent  to  which  the  bones  forming  the  parietes  of  the  antrum  may 
be  dilated  -by  this  disease.  The  patient,  whose  skull  he  has  repre- 
sented, a  woman  about  30  years  of  age,  was  received  into  the 
Westminster  Hospital,  with  an  extraordinary  swelling  upon  the 
right  side  of  the  face,  producing  great  distortion  of  countenance,  but 
not  attended  with  any  discoloration  of  the  skin.  The  basis  of  the 
tumour  extended  upwards  to  the  eye,  which  was  almost^losed,  and 
reached  below  to  the  chin  ;  the  adjacent  angle  of  the  mouth  being 
much  depressed,  and  thrown  out  of  its  line,  and  the  nose  pressed 
aside  towards  the  left  cheek.  In  the  most  prominent  part,  the  tu- 
mour projected  about  4  inches  beyond  the  general  line  of  the  bones 
of  the  face.  On  the  inside  of  the  mouth,  the  tumour  was  very 
large,  having  extended  itself  across  the  palate,  nearly  to  the  oppo- 
site teeth.     The  tumour  was  confined  entirely  to  the  bones  about 

*  CEuvresChirurgicales.     Tome  ii-  p.  165.     Paris,  1813- 


67 

Ithe  upper  jaw ;  it  was  apparently  fleshy,  and  where  it  extended 
across  the  roof  of  the  mouth,  it  was  of  a  florid  red   colour.     The 
teeth  of  the  upper  jaw,  thrown  out  of  their  natural  situation,  formed 
an  angle  with  the  remaining  part  of  the  alveolar  circle.     All  those 
teeth  involved  in  the  extent  of  the  tumour,  were  thus  forced  into 
the  middle  of  the  mouth,  greatly  impeding  deglutition.     The  disease 
was  of  5  years'  standing,  and  had  begun  with  a  small  soft  swelling 
in  the  right  nostril.     In  this  state,  it  had   produced  no  uneasiness. 
I  On  the  presumption  of  its  being  a  polypus,  the  tumour  had  been 
J  partially  extracted  at  different  times.     These  operations  seemed 
ionly  to  accelerate  the  progress  of  the  disease,  aggravating  the  de- 
Igree  of  uneasiness  and  pain  she  now  suffered,   and  hastening  the 
increase  of  the  swelling.     When   the  complaint  had  become  more 
completely  formed,  there  were  two  or  three  teeth,  which  from  their 
I  horizontal  position  were  very  much  in  the  way,  and   troublesome 
(from  their  being  loose.     Although  the  operation  of  removing  them 
(required  no  great  effort,  it  was  attended  with  such  an  heemorrhage 
ia«   brought  the   patient  very  low,  before  it  could  be  effectually 
I  checked.     A  second  violent  bleeding  took  place  about  3  weeks  af- 
terwards, from  a  spontaneous  breach  in  the  softer  part  of  the  tu- 
jmour.     This  reduced  her  so  much,  that  she  languished  only  a 
1  week  longer.     On  dissecting  the  tumour,  it  proved  to  be  a  fleshy 
(mass,  or  excrescence,  not  contained  merel]^  within  the  antrum,  but 
I  surrounding  and  enclosing  all  the  bones  of  the  upper  jaw.     These 
I  bones  had,  from  pressure,  suffered  a  separation  at  their  respective 
I  points  of  union,  with  such  a  degree  of  extension  and  attenuation 
I  of  their  substance,  that  in  many  places  they  were  reduced  to  the 
thinness  of  paper.     The  os  malae  was  detached  from  the  rest  of 
the  bones,  and  though  in  its  natural  state  a  very  solid  bone,  exhib- 
ited a  cribriform   appearance.     The  origin  and  nature  of  the  dis- 
ease cannot  be  a  matter  of  any  doubt.     The  bones  had  most  likely 
remained  uninjured  till  the  soft  fungous  vascular  mass  from  with- 
in the  cavity  of  the  antrum  began  to  operate,  first  by  producing 
absorption  of  the  membrane  lining  that  cavity,   and  then  by  the 
[pressure  of  its  pecuhar  and  partially  organized  texture,  not  exciting 
I  regular  absorption  of  the  bone,  but  sufficiently  loosening  its  struc- 
|ture  to  admit  of  considerable  distention.     In  the  progress  of  the  dis» 
!  ease,  as  might  naturally  be  expected,  the  circulation  in  the  perios- 
I  teum  made  some  effort  towards  repairing  the  mischief  by  the  se- 
cretion of  new  bone,  as  happens  in  cases  of  necrosis,  although  this 
effort,  owing  to  the  almost  disorganized  condition   of  that  mem- 
brane, had  proved  irregular  and  abortive.* 

The  most  remarkable  instance  of  succe^^tiful  extirpation  rf  a  max- 
illary fungus  is  that  which  occurred  to  Dr.  Thomas  White  of 
Manchester.     The  bones  of  the  orbit  appear  to  have  suffered  more 

*  Howship's  Practical  Observations  in  Surgery  and  Morbid  Anatomy,  p.  22. 
London,  I8I61. 


68 

in  this  case  than  in  any  other  on  record.  The  patient  was  a  fe- 
male. In  two  years'  time,  the  tumour,  situated  betwixt  the  left 
zygomatic  process  and  the  nose,  put  on  a  frightful  appearance  ; 
having  grown  to  such  a  bulk  that  it  pressed  the  nostrils  to  one  side, 
so  as  to  stop  the  passage  of  the  air  through  them,  and  thrust  the 
eye  out  of  its  orbit,  so  that  it  lay  on  the  left  temple.  Though  thus 
distorted,  the  eye  still  performed  its  office.  The  swelling  occupied 
the  greatest  part  of  the  left  side  of  the  face,  extending  from  the 
lower  part  of  the  upper  jaw,  to  the  top  of  ihe  forehead,  and  from 
the  farthest  part  of  the  left  temple  to  the  external  catithus  of  the 
eye.  Upon  handling  the  tumour.  Dr.  W.  found  an  unusual  and 
unequal  bony  hardness.  It  was  of  a  dusky  livid  colour,  with  va- 
ricose veins  on  the  surface,  and  there  was  a  soft  tulaercle  projecting 
near  the  nose,  where  nature  had  endeavoured  in  vain  to  relieve  her- 
self Dr.  W.  began  the  operation  with  a  serai-circular  incision 
below  the  dislocated  e5"e,  in  order  to  preserve  that  organ,  and  as 
much  as  possible  of  the  orbicular  muscle  :  then  carrying  the  in- 
cision round  the  external  part  of  the  tumour,  he  brought  it  to  the 
bottom  of  it,  and  then  ascended  to  the  place  where  he  began,  tak- 
ing care  not  to  injure  the  left  wing  of  the  nose.  After  taking  away 
the  external  part  of  the  tumour,  which  was  separated  in  the  mid- 
dle by  an  in)perfect  suppuration,  there  appeared  a  large  quantity  of 
a  matter  hke  rotten  cheese,  in  part  covered  by  a  bony  substance,  so 
carious  as  to  be  easily  broken  through.  Abundance  of  this  matter 
was  scooped  away,  with  a  great  many  fragments  of  rotten  bones. 
Upon  cleansing  the  wound  with  a  sponge,  Dr.  W.  found  the  left 
bone  of  the  nose,  and  the  zygomatic  process,  carious,  and  removed 
them.  He  says  there  were  no  remains  of  the  bones  composing  the 
orbit,  they  being  plainly  destroyed  by  the  same  disease.  The  optic 
nerve  was  denuded  as  far  as  the  dura  mater ;  this  membrane  and 
the  pulsation  of  the  vessels  of  the  brain  were  apparent  to  the  eye 
and  touch.  The  superior  maxillary  bone,  in  the  sinus  of  which 
this  disease  had  had  its  origin,  w^as  surprisingly  distended,  and  in 
some  places  had  become  carious.  The  alveolar  process  was  pro- 
bably in  this  state,  as  Dr.  W.  mentions  that  he  removed  it.  He 
then  applied  the  actual  cautery  to  the  rest  of  the  bones,  taking  care 
not  to  injure  the  eye  and  neighbouring  parts,  which  were  sound. 
The  patient  drew  her  breath  through  the  wound,  and  was  so  in- 
commoded by  the  foetid  matter  flowing  into  her  throat,  that  she 
was  obliged  for  several  weeks  to  lie  on  her  face,  to  prevent  suffoca- 
tion. Notwithstanding  her  miserable  condition,  nature  at  length 
assisted,  laudable  pus  appeared,  sound  flesh  was  generated,  and  the 
patient  recovered.  The  eye  returned  to  its  place,  and  she  enjoyed 
the  perfect  sight  of  it.  The  only  inconvenience  that  remained  was 
a  constant  discharge  of  mucus  from  the  inner  canthus  of  the  eye.* 
Fungus  of  the  maxillary  sinus  occasionally  proves  fatal ;  and  it 

*  White's  Cases  in  Surgery,  p.  135.    London,  1770. 


69 

appears  to  do  so,  like  polypus  of  the  other  cavities  of  the  face,  by 
inducing  pressure  on  the  brain.  "I  have  seen,"  says  Bertraudi, 
"a  polypous  excrescence, so  situated,  that inferiorly  it  destroyed  the 
bones  of  the  palate  ;  it  filled  the  mouth,  and  anteriorly  consumed 
the  maxillary  bone  ;  superiorly  it  pushed  the  eye  almost  out  of  its 
socket,  at  length  it  destroyed  the  roof  of  the  orbit,  pressed  upon  the 
brain,  and  the  patient  died  apoplectic."*  This  termination  of  the 
disease  when  left  to  itself,  and  the  favourable  result  of  extirpation 
in  many  cases  now  recorded,  should  lead  us  at  once  to  propose  the 
operation,  and  not  to  leave  the  tumour  for  a  single  day  to  proceed 
in  its  slow  but  certain  work  of  destruction. 

5.  Pressure  on  the  Orbit  from  the  Sphenoid  Sinus. 

The  sphenoid  sinuses  are  each,  when  fully  developed,  of  size 
sufficient  to  admit  the  end  of  thehttle  finger.  They  lie  before  and 
beneath  the  sella  turcica,  below  and  to  the  inner  side  of  the  fora- 
men opticum,  and  to  the  inner  side  of  the  spheno-orbital  fissure. 
The  partition  which  separates  the  one  sinus  from  the  other,  rarely 
runs  in  the  middle  plane  of  the  body.  They  communicate  with 
the  upper  meatus  of  each  nostril,  and  like  the  other  sinuses  of  the 
face,  are  lined  by  a  continuation  of  the  Schneiderian  membrane. 
From  analogy,  then,  we  should  conclude  that  they  are  subject  to 
the  same  diseases  as  the  frontal  and  maxillary  sinuses ;  but  I  know 
of  no  instance  on  record  in  which  the  sphenoid  sinuses  were  dilated 
by  inflammation  or  polypus.  The  consequences  of  dilatation  of 
these  cavities  on  the  orbit,  and  on  the  vessels  and  nerves  of  the  or- 
bit, may  readily  be  conceived.  They  could  expand  easily,  neither 
downwards  nor  backwards  ;  and  were  they  to  press  either  upwards 
or  outwards,  they  would  deform  the  posterior  part  of  the  orbit,  im- 
pede the  circulation  of  blood  to  and  from  the  eye,  and  destroy  its 
sensitive  power  and  motion. 

6.  Pressure  on  the  Orbit  from  the  Cavity  of  the  Cranium. 

In  some  diseased  states  of  the  encephalon,  the  orbits  are  pressed 
forward,  so  that  their  apex  approaches  to  their  base,  or,  in  other 
words,  they  become  much  shallower  than  natural,  and  the  eyeballs 
protuberant.  This  takes  place  in  chronic  hydrocephalus.  I  have 
now  before  me  the  skull  of  an  adult,  so  much  dilated  by  a  diseased 
state  of  the  brain,  which  must  have  supervened  in  adult  age,  that 
the  distance  from  the  meatus  auditorius  to  the  crown  of  the  head, 
which  commonly  measures  6  inches,  amounts  to  7^  inches ;  while 
almost  every  part  of  its  parietes  is  so  much  thinned  in  consequence 
of  pressure,  as  to  be  diaphanous.  The  ordinary  depth  of  the  orbit  is 
1  inch  and  7-lOths,  whereas  in  this  skull  it  strikes  one  at  the  first 
glance  as  unnaturally  shallow,  and  on  measurement  is  found  only 
1  inch  and  1-iOth  in  depth. 

♦  Traite  des  Operations  de  Chirurgie,  traduit  par  Sollier,  p.  303.     Paris,  1794. 


70 

In  another  set  of  cases,  one  or  other  orbit,  rarely  iDoth  at  once, 
although  often  the  one  and  then  the  other,  are  not  merely  deformed 
by  the  pressure  arising  from  disease  within  the  cranium,  but  some . 
part  of  their  walls,  and  especially  their  roof,  becomes  involved  by 
the  disease  of  the  brain  or  of  its  membranes,  inflames,  is  partially 
absorbed,  or  is  destroyed  by  caries  or  necrosis.  Under  such  cir- 
cumstances, death  is  generally  preceded  by  amaurosis,  exophthal- 
mos, and  sometimes  exophthalmia.* 

Many  cases  might  be  quoted  of  diseased  dura  mater  producing 
the  destruction  of  the  orbit  by  pressure  and  absoiption.  Most  of 
the  cases  of  this  kind  on  record  appear  to  have  succeeded  to  inju- 
ries of  the  head,  by  blows  or  falk.  In  some  of  them,  the  dura 
mater  was  diseased,  without  any  remarkable  morbid  change  of 
the  brain ;  in  others,  the  brain  was  likewise  affected.  In  some, 
the  disease  of  the  dura  mater  was  fungous  ;  in  others  hydatiginous 
or  encysted. 

Disease  originating  in  the  pia  mater  or  in  the  brain,  and  de- 
stroying the  orbit,  must  necessarily  be  rare:  but  the  case  already 
quoted  from  Mr.  Hunter  demonstrates  the  possibility  of  such  an 
event. 

The  following  cases  are  interesting,  and  will  serve  to  illustrate 
the  influence  of  diseases  within  the  cranium,  over  the  orbit  and 
its  contents. 

1.  A  case  by  Paaw,  is  recorded  among  the  HistoricB  Anato- 
miccB  of  Bartholin,  of  a  child,  3  years  of  age.  whose  left  eye  was 
entirely  protruded  from  its  orbit.,  and  enlarged  to  a  great  size.  In 
a  few  months  the  child  died,  and,  on  dissection,  a  fungous  tumour, 
adherent  to  the  dura  mater  -which  covered  the  roof  of  the  orbit, 
was  found  to  be  the  cause  of  the  exophthalmia.  The  brain  was 
sound. t 

2.  A  man.  51  years  of  age,  fell  from  his  horse,  and  received  a 
severe  contusion  on  the  head,  followed  by  pain,  which  gradually 
subsided.  Four  years  afterwards,  his  memorv  began  to  fail :  from 
day  to  day,  this  defect  increased,  till  he  could  no  longer  recollect 
what  he  had  uttered  a  moment  before.  Frequent  and  violent 
epileptic  fits  succeeded  :  but  appeared  to  5'ield  to  different  remedies, 
employed  during  6  months.  Most  severe  and  uninterrupted  head- 
ach  next  supervened.  No  remedy  was  found  to  calm  this  symp- 
tom :  and  after  6  months,  the  patient  died.  For  6  weeks  before 
his  death,  the  left  eye  had  been  turned  from  its  natural  position 
in  the  orbit.+     On  that  side  of  the  head,  the  pain  had  been  com- 

*  Louis  on  Fungous  Tumours  of  the  Dura  Mater,  in  the  Memoirs  of  the  French 
Academy  of  Surgery.  Lieutaud,  Historia  Anatomico-Medica.  Tom.  ii.  p.  195, 
Parisiis,  1767.  Beer,  Lehre  don  den  Aucrenkrankheiten.  Vol.  ii.  p.  579.  Wien, 
1817.  Abercrombie  on  Diseases  of  the  Brain,  pp.  194,  443.  Ed  in.  1828.  Hooper's 
Morbid  Anatomy  of  the  Human  Brain.     London,  18-26. 

t  Memoires  de  1' Academic  de  Chirurgie.     Tome  xiii.  p.  27G.     Paris,  1774. 12mo. 

t  Contourne  par  la  force  du  spasme. 


71 

paratively  slight.  On  dissection,  the  two  tables  of  the  middle  an- 
terior part  of  the  right  parietal  bone  were  found  carious  to  the  ex- 
tent of  a  denii-jiorin  ;  while  various  other  places  of  smaller  extent 
were  similarly  affected.  A  fungous  tumour,  adherent  to  the  dura 
mater,  had  produced  the  absorption  of  the  roof  of  the  left  orbit,  and 
thus  made  its  way  into  that  cavity.  The  same  tumour  had  de- 
stroyed the  cribriform  plate  of  the  ethmoid  bone ;  and  the  corres- 
ponding portion  of  brain  was  also  diseased.*  Had  the  patient  sur-  ' 
vived  for  any  considerable  time  longer,  there  can  be  no  doubt  that 
the  existence  of  this  fungous  tumour,  pressing  through  the  orbit, 
would  have  been  manifested  still  more  distinctly,  by  external 
changes. 

3.  Marechal  had  under  his  care  a  young  man,  20  years  of  age, 
whose  left  eye  was  prominent  and  turned  outwards,  in  consequence, 
apparently,  of  a  tumour  at  the  inner  angle  of  the  eye,  attended  by 
headach,  giddiness,  watering  of  the  eye,  and  dryness  of  the  nos- 
tril. Marechal  attacked  the  tumour  with  caustic,  and  then  punc- 
tured the  eschar,  when  there  flowed  out  two  or  three  table -spoonfuls 
of  lymph,  a  little  reddish  in  colour  ;  after  wiiich  the  eye  was  re- 
stored almost  to  its  natural  place.  On  being  appointed  surgeon 
to  Louis  XIV.,  Marechal  handed  the  patient  over  to  Petit.  When 
the  eschar  separated,  something  like  a  vesicle  presented  itself  in  the 
middle  of  the  opening.  On  puncturing  this  vesicle  with  the  lan- 
cet, a  fluid  escaped  similar  to  what  had  previously  been  discharged, 
only  less  in  quantity.  Two  days  after,  a  third  was  opened  in  the 
same  way,  but  discharged  very  little.  The  eye  became  again 
displaced  outwards  and  forwards,  as  it  had  been  at  the  first ;  the 
head  became  heavy,  fever  supervened,  and  in  a  short  time  the  pa- 
tient died  lethargic.  On  opening  the  head,  nothing  remarkable 
was  found  in  the  brain ;  the  dura  mater  investing  the  lower  part 
of  the  middle  lobe  of  the  cerebrum  appeared  considerably  elevated, 
and  on  endeavouring  to  detach  it  from  the  squamous  portion  of 
the  temporal  bone,  it  was  found  united  to  the  bone,  and  the  bone 
changed  into  a  cartilaginous  or  fleshy  substance.  The  roof  of  the 
orbit  was  changed  in  like  manner ;  while  three  hydatids  or  vesi- 
cles, full  of  reddish  fluid,  and  each  about  the  size  of  a  walnut, 
were  found,  one  in  the  orbit,  a  second,  half  in  the  orbit  half  in  the 
cranium,  and  the  third,  in  the  hollow  formed  by  the  union  of  the 
sphenoid  with  the  petrous  and  squamous  portions  of  the  temporal 
bone.  That  hollow,  as  w^ell  as  the  sphenoid,  where  it  forms  the 
optic  foramen,  was  also  softened.  In  fact,  this  altered  state  of 
bone  extended  from  the  petrous  portion  of  the  temporal  to  the  inner 
angle  of  the  eye,  the  os  planum  and  the  os  unguis  being  likewise 
affected.1 

*  Gluoted  from   Jauchius,  by  Louis,  in   his  paper  on  Fungous  Tumours  of  the 
Dura  Mater ;  Meraoires  de  TAcademie  de  Chirurgie.     Touse  ziii.  p.  62.  Paris,  1774. 
12mo. 
I      t  Petit,  Traite  des  Maladies  des  Os.     Tom.  ii.  p.  325,     Paris,  1759. 


72 

4.  A  robust  maa,  aged  48  years,  whose  employment  led  him  to 
the  frequent  lifting  of  heavy  loads  into  and  out  of  a  cart,  was  in  the 
act,  along  with  another  labourer,  of  lowering  from  his  cart  a  pack- 
age of  above  oOOlbs.  weight,  when  his  foot  slipping,  he  was  struck 
by  the  package  on  the  head.  No  bad  effects  appeared  immediately 
to  result,  so  that  he  not  only  carried  this  load  away  to  its  destina- 
tion, after  placing  it  on  his  head,  but  continued  for  five  weeks  to 
pursue  his  ordinar}''  occupation.  After  that  period,  he  began  to 
complain  of  feelings  of  internal,  obtuse,  pressing  pain,  in  that  part 
of  the  head  where  the  right  parietal  bones  form,  along  with  the 
frontal,  the  coronal  suture  :  and  the  pulse  became  quick,  full,  and 
hard.  To  these  symptoms,  there  followed  epileptic  fits,  which  were 
renewed  several  times  in  the  course  of  the  day.  The  fever  and 
pain  of  head  became  mitigated,  digestion  and  nutrition  were  unim- 
peded, but  the  patient  continued  for  more  than  a  year  totally  unfit 
for  any  employment,  on  account  of  the  frequency  of  the  epileptic 
attacks.  About  fifteen  months  after  the  accident,  the  pain  of  the 
head  again  increased,  to  such  a  degree,  as  to  deprive  him  of  rest 
both  night  and  day,  and  to  cause  such  suffering,  that  he  could  not 
help  crying  out.  Violent  fever  and  delirium  accompanied  the  pain. 
These  symptoms  continued  for  several  weeks,  but  the  epilepsy 
ceased.  The  pain  gradually  descended  to  the  right  ear  and  eye, 
and  in  proportion  as  it  became  more  severe  in  the  orbit,  it  subsided 
in  the  upper  part  of  the  head.  The  eyeball  became  inflamed  and 
swollen,  and  was  protruded  from  the  orbit.  On  raising  the  upper 
eyelid,  the  cornea  was  seen  to  be  turbid,  the  pupil  expanded  and 
immoveable,  the  iris  green,  and  vision  very  imperfect.  Onyx  fol- 
lowed, commencing  at  the  lower  edge  of  the  cornea,  and  advancing 
till  the  w^hole  cornea  w3-s  affected.  Violent  pain  continued,  pro- 
ceeding from  the  bottom  of  the  orbit  towards  the  external  parts  of 
the  eye,  and  attended  at  length  by  a  discharge  of  blood  from  the 
inner  canthus  and  riglit  nostril.  After  this  the  pain  ceased,  and  the 
patient  had  onl}^  two  fits  of  epilepsy.  The  left  eye,  with  the  ex- 
ception of  a  little  redness  at  the  inner  canthus,  was  healthy  ; 
memory  failed,  and  the  vital  functions  became  enfeebled.  About 
eighteen  months  after  the  accident,  the  epileptic  fits  returned,  they 
were  more  frequent  and  more  violent  than  before,  and,  some  few 
short  lucid  intervals  excepted,  the}^  were  attended  with  constant 
stupor,  and  absence  of  mind.  Respiration  became  impeded,  and 
the  patient  died  in  violent  convulsions.  On  sav.'ing  through  the 
cranium,  the  bones  of  the  right  side  were  seen  to  be  bent  outwards^ 
they  were  harder  than  those  of  the  left,  their  two  tables  thicker, 
and  their  diploe  wanting.  The  vessels  of  the  dura  mater  were 
dilated,  and  filled  with  blood.  That  membrane  firmly  adhered  at 
every  point  to  the  inner  surface  of  the  skull,  except  over  the  roof  of 
the  orbit,  where  a  considerable  portion  of  it  (ad  incmi  majoris 
niagnitudinem)  was  separated  from  the  bone,  thickened,  and  in  a 
state  of  suppuration.     The  dura  mater,  tunica  arachnoidea,  and  pia 


73 

mater,  were  at  that  spot  united  together,  and  firmly  adherent  to  the 
brain.  The  corresponding  part  of  the  roof  of  the  orbit  was  rough. 
The  substance  of  the  right  hemisphere  of  tlie  brain  was  softer  than 
that  of  the  left,  and  of  a  dirt}^  brownish  white  colour ;  the  right  la- 
teral ventricle  was  enlarged,  and  filled  with  thin  fluid  ;  the  lower 
surface  of  the  right  anterior  and  middle  lobes  was  occupied  by  a 
number  of  steatomata,  from  the  size  of  a  pea  to  that  of  a  filbert,  and 
corresponding  to  the  destroyed  portion  of  the  dura  mater,  and  the 
rough  part  of  the  roof  of  the  orbit.  The  Gasserian  ganglion,  and 
its  three  branches,  were  surrounded  by  a  firm  cartilaginous  mass ; 
the  motor  oculi  was  compressed  and  changed  in  colour.  The  ab- 
ducens  was  contracted  to  the  size  of  a  small  thread,  while  within 
the  cranium  ;  but  both  it  and  the  motor  oculi  were  of  their  ordinary 
thickness  within  the  orbit.  The  internal  surface  of  the  right  side 
of  the  cranium,  upwards  to  the  middle  of  the  frontal  bone,  and 
backwards  over  the  little  and  great  wings  of  the  sphenoid  to  the 
sella  turcica,  was  rough.  The  cartilaginous  mass  surrounding  the 
Gasserian  ganglion  was  found  to  proceed  through  the  spheno-or- 
bital  fissure  into  the  orbit,  surrounding  the  optic  nerve,  and  so  fill- 
ing up  the  space  between  the  superior,  external,  and  inferior  straight 
muscles,  as  to  envelop  their  origin  and  vessels,  the  posterior  part  of 
the  naso-ciUary  nerve,  the  inferior  branch  of  the  motor  oculi,  the 
abducens  nerve,  and  the  opthalmic  ganglion.  The  same  cartila- 
ginous substance  was  traced  through  the  spheno-maxillary  fissure, 
into  the  zygomatic  fossa.* 


CHAPTER  11. 

DISEASES  OF  THE  SECRETING  LACHRYMAL  ORGANS. 


SECTION  I. — -INJURIES  OP  THE  LACHRYMAL  GLAND  AND  DUCTS. 

It  will  be  difficult  to  wound  the  lachrymal  gland,  with  any  ordi- 
nary instrument,  penetrating  into  the  cavity  of  the  orbit ;  but  still 
it  might  be  possible  to  reach  it,  for  instance,  with  a  penknife,  driven 
upwards,  backwards,  and  outwards,  into  the  fossa  lachrymalis  ; 
and  we  can  easily  enough  suppose  the  excretory  ducts  of  the  gland 
to  be  divided  in  such  a  penetrating  wound.  The  effects  of  such  a 
wound  will  be  apt  to  resemble  those  of  a  wounded  parotid  gland  or 

*  Commentatio  Pathologico-Anatomica  exhibens  Morbum  Cerebri  Oculique  sin- 
gularem.     Auctore  F.  A.  Landmann.     Lipsise,  1820. 


74 

duct ;  thai,  is  to  say,  the  frequent  distiUment  of  tears,  like  that  of 
saHva,  will  be  likely  to  prevent  the  healing  of  the  wound,  and  a 
fistula  lachrymalis  vera,  as  it  is  called,  to  follow.  1  know  of  no 
such  case  on  record  ;  but  the  thing  is  possible.  A  penetrating 
wound,  then,  v/hich  we  suspect  may  have  penetrated  to  the  lach- 
rymal gland,  or  divided  some  of  its  ducts,  w^e  should  endeavour  tO' 
unite  with  more  than  common  care  ;  employing,  for  that  purpose, 
sutures,  strips  of  adhesive  plaster,  and  a  compress  and  roller,  and 
enjoining  the  patient  to  keep  the  eye  as  much  as  possible  at  rest;. 
till  the  cure  be  completed. 


SECTION    II. XEROMA. 


,1 


Xeroma  or  dryness  of  the  eye,  from  suppression  of  the  secretion 
of  the  lachrymal  gland,  is  not  so  much  a  disease  existing  by  itself^ 
as  a  symptom  of  various  other  diseases.  In  some  cases,  it  arises 
from  a  disordered  state  of  the  lachrymal  gland  ;  in  other  cases^  this 
gland  ceases  to  fulfil  its  ofiice,  on  account  of  its  sympathy  with  the 
brain. 

We  have  an  instance  of  xeroma,  of  the  first  kind,  in  the  disease 
called  lachrymal  tumour  in  the  lachrymal  gland.  I  am  not  cer- 
tain that  xeroma  is  a  common,  though  it  may  be  an  occasional 
symptom,  in  inflammation  of  the  gland.  The  assertion  that  it  ac- 
companies scirrhus  or  enlargement  of  that  body,  is  contradicted  by 
the  cases  related  by  Mr.  Todd,  and  Dr.  O'Beirne.  Yet  we  can 
scarcely  suppose  that  the  function  of  the  lachrymal  gland  will  go 
on  without  impediment,  when  its  substance  is  either  inflamed  or 
indurated. 

We  meet  with  xeroma  as  a  frequent  attendant  on  the  incipient 
stage  of  amaurosis  ;  and  we  may  hail  as  a  favourable  sign  in  such 
cases,  the  return  of  the  lachiymal  secretion,  for  we  invariably  find 
that  after  this  change,  the  vision  begins  to  improve. 

We  may  regard  the  xeroma  which  occasionally  attends  deep 
grief,  as  a  purely  nervous  or  sympathetic  phenomenon. 

In  all  these  cases,  when  we  look  at  the  eye,  no  appearance  of 
dryness  is  to  be  observed ;  for  the  mucous  secretion  of  the  con- 
junctiva is  not  affected.  The  eye  looks  as  moist  and  shppery  as 
ever,  but  the  patient  complains  that  it  is  never  wet ;  or  if  it  be  at 
times  bedewed  with  tears,  great  rehef  is  experienced,  evidently 
showing  that  the  dryness  depends  on  want  of  the  lachrymal,  not  of 
the  conjunctival,  secretion. 

If  xeroma  seems  to  depend  on  inflammation  of  the  lachrymal 
gland,  or  if  we  suspect  any  incipient  affection  of  that  body  likely  to 
lead  to  its  enlargement  or  disorganization,  local  bleeding,  and  the 
antiphologistic  regimen,  will  be  practised.  If  the  affection  appears 
to  be  nervous,  purgatives,  tonics,  and  antispasmodics,  may  be  had 


75       ' 

urecourse  to.     The  influence  of  music  has  sometimes  been  very  re- 
markable in  removing  the  xeroma  attendant  on  grief.* 

SECTION  III. EPIPHORA^ 

This  is  the  reverse  of  the  last  disease ;  for  the  tears  are  secreted 
and  discharged  too  abundantly,  and  too  frequently.  Like  xeroma, 
however,  epiphora  may  be  regarded  rather  as  a  symptom  than  as  a 
disease  in  itself 

Diagnosis.  Epiphora  must  not  be  confounded  with  stillicidium 
lachrymarum.  The  difference  is,  that  the  latter  is  merely  a  drop- 
ping of  tears,  from  some  incapability  in  the  excreting  parts  of  the 
lachrymal  organs  to  remove  the  mucus  of  the  conjunctiva  and  the 
tears,  after  they  have  done  their  duty ;  while  epiphora  is  a  disease 
of  the  secreting  lachrymal  organs,  or  an  over-discharge  of  tears. 

Causes.  Any  mechanical  or  chemical  irritation,  applied  to  the 
conjunctiva,  instantly  produces  a  discharge  of  tears,  or  epiphora,  so 
that  the  foreign  body  may  be  forcibly  washed  away,  or  the  chem- 
ical  substance  diluted. 

Inflammation  of  the  eye,  or  eyelids,  and  especially  strumous  or 
pustular  inflammation  of  the  conjunctiva,  is  an  extremely  frequent 
cause  of  epiphora.  We  observe  that  children,  who  are  the  general 
subjects  of  that  species  of  ophthalmia,  if  they  attempt  to  open  the 
eye,  are  affected  with  instant  epiphora,  and  spasm  of  the  orbicularis 
palpebrarum.  We  can  be  at  no  loss  to  explain  this  connexion 
between  the  eyelids,  conjunctiva,  and  lachrymal  gland,  when  we 
recall  to  mind  that  the  lachrymal  nerve,  having  passed  through  the 
lachrymal  gland,  spends  its  ultimate  branches  in  the  conjunctiva, 
orbicularis  palpebrarum,  and  skin  of  the  upper  eyelid.*  In  many 
cases  of  strumous  conjunctivitis,  the  redness  is  extremely  slight, 
perhaps  scarcely  an  enlarged  vessel  is  to  be  seen,  and  as  yet  no 
pustules  or  minute  pimples  have  made  their  appearance,  but  the 
epiphora,  and  intolerance  of  light,  are  extremely  acute. 

Epiphora  is  occasionally  a  symptom  of  disordered  digestion, 
especially  in  children,  and  of  worms  in  the  intestines.  Indeed, 
even  when  connected  with  strumous  ophthalmia,  we  may  regard 
both  the  ophthalmia  and  the  epiphora,  as  originating,  in  many 
cases  at  least,  in  improper  food,  and  disorder  of  the  digestive  organs. 

Treatment.  We  scarcely  require  to  prescribe  for  epiphora 
alone.  I  have  seen  it  completely  and  permanently  removed  by  an 
emetic.  Purgatives,  followed  by  tonics,  and  occasionally  antacids, 
will  be  found  highly  useful  in  removing  some  of  the  more  com- 
mon causes  of  the  disease.  A  mixture  of  rhubarb  and  supercar- 
bonate  of  soda,  repeated  every  day,  or  every  second  day,  and  fol- 
lowed up  by  a  course  of  the  sulphate  of  quina,  is  a  plan  of  treatment 
which  I  have  often  found  effectual. 

*  Dictionaire  des  Sciences  Medicales.     Tome  xxxv.  p.  71;     Paris,  1819. 
t  Socmmerring,  Abbildungen  des  Menschlichen  Auges.     p.  43.     Frankfurt  am 
1  Main,  1801. 


76 

Of  local  remedies,  the  most  useful  are  tlie  vapour  of  laudanum, 
and  the  lunar  caustic  solution.  Into  a  cup  of  boiling  water,  a  tea- 
spoonful  of  laudanum  is  mixed,  the  cup  held  under  the  eye,  the 
eyelids  opened,  and  the  vapour  allowed  to  come  into  contact  with 
the  conjunctiva.  This  may  be  done  twice  or  thrice  a  day.  No- 
thing reheves  more  the  irritability  of  the  conjunctiva,  on  which 
epiphora  so  frequently  depends,  than  a  solution  of  two  or  three 
grains  of  lunar  caustic  in  an  ounce  of  distilled  water,  dropped  on 
the  eye  with  a  camel  hair  pencil  once  a  day. 

Blisters  are  useful  in  epiphora.  They  are  more  likely  to  be  so, 
when  applied  before  the.  ear,  or  on  the  temple,  as  they  will  then  act 
more  directly  on  the  branches  of  the  deep  temporal  nerves,  which 
anastomose  with  the  lachrymal  nerve. 


SECTION    IV. INFLAMMATION    AND    SUPPURATION    OF    THE 

LACHRYMAL    GLAND. 

The  lachrymal  gland  is  liable  to  become  inflamed.  Children  of 
a  strumous  constitution  are  the  general  subjects  of  this  affection, 
which  is  by  no  means  a  common  one.  The  cellular  membrane 
which  connects  the  acini  of  the  gland  is  probably  the  original  seat 
of  the  inflammation. 

Symptoms.  Pain  in  the  seat  of  the  gland,  and  growing  fulness 
above  the  external  angle  of  the  eyelids,  are  the  first  symptoms  which 
are  remarked.  The  swelUng  becomes  red  and  tense  ;  the  upper 
lid  can  be  raised  with  difficulty,  if  at  all :  the  conjunctiva  is  inflam- 
ed ;  the  eyeball  is  pushed  forwards  and  inwards  :  and  at  last,  when 
the  inflamed  gland  is  enlarged  to  the  utmost,  the  sympathetic  swell- 
ing of  the  neighbouring  cellular  substance  advances  so  much  in 
front  of  the  globe  of  the  eye,  as  completely  to  conceal  it.  The  pain 
in  the  orbit  and  head  becomes  more  and  more  severe.  Unless  the 
progress  of  the  inflammation  is  arrested,  fever,  restlessness,  and  de- 
lirium, usher  in  the  local  symptoms  of  suppuration  ;  fluctuation 
becomes  more  and  more  distinct ;  and  at  last  the  matter  points,  and 
bursts  through  the  upper  eyelid.  Unfortunately,  it  but  too  frequently 
happens,  that  before  this  discharge  is  afforded  to  the  matter  by  the 
spontaneous  bursting  of  the  abscess,  the  bone  has  become  affected, 
probably  fi'ora  pressure  :  the  case  becomes  a  very  tedious  one,  ectro- 
pium  of  the  upper  eyehd  follows,  and  the  fistula,  as  has  already 
been  explained,  does  not  heal  till  the  bone  becomes  healthy,  or  till 
the  diseased  portion  of  it  is  discharged,  which  may  not  be  accom- 
plished for  years. 

Causes.  Blows  over  the  external  angular  process  of  the  frontal 
bone,  and  exposure  to  cold,  are,  1  beheve,  the  common  causes  of  in- 
flammation of  the  lachrymal  gland.  Mr.  Todd,  however,  has  stated, 
that  the  greater  number  of  cases  which  had  fallen  under  his  observa- 
tion, were  not  idiopathic,  but  succeeded  to  inflammation  of  the  con- 
junctiva, or  some  other  form  of  ophthalmia.     He  had  known  inflam- 


77 

mation  of  the  lachrymal  gland  to  accompany  the  psorophthalmia  of 
childien,  when  that  disease  was  severe,  or  aggravated  by  neglect, 
exposure  to  cold,  or  by  the  incautious  use  of  stimulating  or  astrin- 
gent applications.  He  is  also  of  opinion,  that  in  some  cases,  inflam- 
mation of  this  gland  ushers  in  the  ordinary  forms  of  ophthalmia, 
and  gives  rise  to  symptoms  generally  attributed  to  inflammation  of 
the  eye  alone.* 

Forms.  Besides  the  acute  form  of  this  disease,  Mr.  Todd  has 
described  a  chronic  inflammation  of  the  lachrymal  gland,  almost 
entirely  confined  to  the  early  periods  of  life,  and,  in  all  probability, 
depending  on  a  scrofulous  predisposition.  In  this  chronic  affeciion, 
there  is  an  obvious  enlargement  of  the  gland,  with  occasional  oedema- 
tous  tumefaction  of  the  upper  eyelid;  the  patient  seldom  complains 
Df  pain,  but  generally  of  a  sensation  of  fulness  above  the  globe,  and 
an  inabihty  to  move  the  eye  of  that  side  as  freely  as  the  other. 
On  making  pressure  between  the  globe  of  the  eye  and  the  temporal 
3xtremity  of  the  upper  edge  of  the  orbit,  an  immediate  and  copious 
discharge  of  tears  is  produced.  Mr.  T.  appears  inclined  to  attribute 
strumous  or  pustular  conjunctivitis,  to  the  morbid  secretion  of  the 
lachrymal  gland,  during  the  course  of  chronic  inflammation  ;  and 
mentions  the  case  of  a  j'^oung  lady,  who,  on  one  side  had  chronic 
nflam  mation  of  the  gland,  with  frequent  attacks  of  pustular  con- 
unctivitis,  while  on  the  other  side,  the  gland  was  healthy,  and  no 
ophthalmia  ever  occurred. 

Besides  chronic  inflammation,  the  specific  nature  of  which  is  pro- 
bably equivocal,  Mr.  T.  represents  the  lachrymal  gland  as  subject 
;o  an  enlargement  more  decidedly  scrofulous  ;  characterized  by 
slowness  of  progress,  although  it  sometimes  acquires  considerable 
nagnitude;  absence  of  pain  ;  the  tumour  presenting  a  surface  m.ore 
)r  less  lobulated  ;  and  the  constitution  and  age  of  the  patient.  He 
states  that  in  some  instances  this  affection,  after  a  certain  period, 
vvill  continue  stationary  for  many  months,  or  even  for  years,  while 
n  others  it  will  undergo  that  form  of  suppurative  inflammation 
3eculiar  to  scrofulous  glands,  and  will  thus  prove  a  tedious  and  trou- 
blesome disease.  It  is  probable  that  this  scrofulous  enlargement  of 
,he  lachrymal  gland  has  sometimes  been  mistaken  for  scirrhus, 
jspecially  when  both  glands  have  been  affected  in  the  same  in- 
iividual.t 

Treatment.  In  acute  inflammation  of  the  lachrymal  gland, 
eeches  are  to  be  applied  liberally  to  the  upper  eyelid,  forehead,  and 
emple  ;  purgatives,  rest,  cooling  lotions,  and  the  whole  antiphlo- 
pstic  plan  are  to  be  adopted  ;  venesection  is  to  be  employed,  if  the 
'ever  runs  high. 

When  the  symptoms  become  indicative  of  the  formation  of  mat- 
j;er,  a  warm  emolUent  poultice  is  to  be  applied   over  the  swefling. 

•  Dublin  Hospital  Reports,  Vol.  iii.  p.  408.     Dublin,  1822. 

t  See  Daviel's  2d  and  3d  Cases,  in  the  London  Medical  Gazette,  Vol.  iii.  pp.  523, 
)24.    London,  1829. 


78 

When  the  matter  has  fairly  formed,  it  must  be  evacuated.     I  doubt 

whether  it  will  be  possible  to  do  this,  under  the  upper  eyelid,  with 
a  small  knife,  directed  through  the  conjunctiva,  towards  the  seat  of 
the  gland.  If  this  plan  is  found  possible,  it  ought  to  be  followed. 
If  not,  the  abscess  must  be  opened  througli  the  upper  eyelid,  the 
incision  being  made  parallel  to  the  superior  edge  of  the  orbit. 
Matter  will  continue  to  be  discharged  for  some  time,  gradually  di- 
minishing, and  at  length  drying  up  ;  but  it  occasiooally  happens, 
that  the  opening  contracts  to  a  very  small  diameter,  and  continues 
to  discharge  tears,  forming  what  is  called  a  true  lachrymal  fistula. 
This  is  still  more  apt  to  be  the  case,  if  the  abscess  has  been  allowed 
to  burst  of  itself. 

Should  we  be  called  to  a  case  of  this  sort,  only  after  the  abscess 
has  burst  of  itself,  we  ought  to  examine  the  sinus  with  a  probe,  to 
discover  whether  the  bone  is  diseased,  wash  it  out  daily  with  a 
small  syringe  and  some  stimulating  injection,  keep  it  open  with  a 
tent  if  the  bone  be  diseased,  and  especially  if  there  be  any  suspicion 
that  the  diseased  piece  of  bone  is  loose  and  likely  to  come  away, 
and  forewarn  the  patient,  or  his  friends,  of  the  ectropium  and  de- 
formity which  will  probaljly  ensue,  and  which  are  very  difficult  of 
removal,  even  by  operation. 

In  cases  of  chronic  inflammation  of  the  lachrymal  gland,  or  of 
slow  strumous  enlargement,  the  antistrumous  regimen  is  to  be  pre- 
scribed :  nourishing  food,  sea-air,  tonics,  &c.  The  occasional  ap- 
plication of  a  few  leeches  to  the  neighbourhood  of  the  gland :  a 
succession  of  small  blisters  to  the  forehead,  temple,  and  back  of  the 
ear  ;  small  doses  of  calomel,  or  blue  pill  at  night,  with  a  saline  or 
other  laxative,  next  morning,  will  also  prove  beneficial.  If  stru- 
mous inflammation  of  the  gland  ends  in  suppuration,  we  must  not 
allow  the  skin  to  become  extensively  diseased,  but  employ  the  lan- 
cet as  soon  as  fluctuation  is  distinct. 


SECTION    V. EXLARGE3IENT    OR     SCIRRHL'S    OF    THE    LACHRY- 
MAL   GLAXD. 

The  lachrymal  gland,  like  other  glands  of  similar  structure,  is 
subject  to  a  slow  enlargement,  which  has  generally  been  regarded 
as  scirrhous. 

Symptoms.  This  disease  is  known,  we  are  told,  b}'  dryness  of 
the  eye  ;  but  this  statement  appears  to  be  incorrect,  for  in  the  cases 
recorded  by  Mr.  Todd  and  Dr.  0"Beirne,  epiphora  existed,  not 
xeroma.''  The  following  symptoms  are  less  equivocal ;  namely, 
lancinating  pain  in  the  upper  and  external  part  of  the  orbit ;  en- 
largement of  the  gland  till  it  forms  a  projecting  tumour,  which, 
through  the  extended  skin  of  the  upper  eyelid,  is  felt  to  be  hard  and 

*  Dublin  Hospital  Reports.     Vol.  iii,  pp.  420,  421,  427.     Dublin,  1822. 


79 

lobulated  ;  projection  of  the  eyeball  downwards,  inwards,  and  for- 
wards ;  dimness  of  sight ;  double  vision,  and  at  length  blindness. 
If  the  disease  be  neglected,  or  the  patient  refuse  to  submit  to  pro- 
per treatment,  the  temporal  side  of  the  orbit  in  some  cases  begins  to 
DC  dilated,  the  eyeball  actually  resisting  the  pressure  of  the  tumour 
Detter  than  the  bones  ;  but  more  commonly,  the  eyeball  inflames, 
md  bursts,  its  contents  are  absorbed,  the  gland  goes  on  to  enlarge 
;il]  it  completely  fills  and  distends  the  orbit,  the  remains  of  the  eye- 
Dall  are  seen  lying  on  the  front  of  the  tumour,  which,  still  continu- 
ng  to  grow,  presses  itself  downwards  through  the  spheno-maxillary 
issure,  and  even  deforms  the  brain  by  pressure.  The  patient  dies 
A'orn  out  by  pain  and  fever. 

This  disease  of  the  lachrymal  gland  does  not,  as  far  as  I  know, 
iffect  the  lymphatic  system,  nor  does  it  appear  to  undergo  any 
hing  like  cancerous  ulceration.  It  may  therefore  be  doubted,  if 
t  be  scirrhus.  It  is  also  worthy  of  observation,  that  the  globe  of 
he  eye,  and  the  other  contents  of  the  orbit,  may  be  extensively 
Hseased,  and  the  lachrymal  gland  remain  unaffected.  I  have  seen 
t  somewhat  enlarged  and  hardened  in  a  case  of  disorganization  of 
he  eye  from  syphihtic  inflammation ;  but  in  cases  of  fungus  of 
he  retina,  rendering  extirpation  of  the  contents  of  the  orbit  neces- 
ary,  I  have  repeatedly  found  the  gland  perfectly  sound.  Scirrhus 
)f  the  lachrymal  gland,  like  inflammation  of  the  same  part,  occa- 
ionally  brings  on  caries  of  the  fossa  lachrymahs. 

Fatal  case.  Some  years  ago,  I  inspected  the  body  of  Mrs.  F. 
iged  60  years,  a  patient  of  the  late  Dr.  G.  C.  Monteath.  Some 
^ears  before  her  death,  she  became  affected  with  protrusion  of  the 
ight  eye  downwards,  inwards,  and  forwards.  After  some  years, 
;he  eye  burst.  We  found  the  empty  sclerotica  lying  on  the  front 
fthe  tumour,  which  was  white  and  granular,  the  grains  being 
vidently  the  enlarged  acini  of  the  lachrymal  gland.  It  was  as 
arge  as  a  man's  fist,  occupying  a  much  expanded  orbit,  and  pres- 
ing  itself  down  into  the  spheno-maxillary  fissure.  It  had  been 
he  means  of  destroying  by  absorption,  the  roof  of  the  orbit,  which 
\vas  still  covered  by  dura  mater,  except  in  some  few  points,  where 
:he  tumour  and  the  brain  were  in  contact.  It  had  deformed  the 
■rain  in  a  remarkable  degree,  having  pressed  the  lower  surface  of 
he  anterior  lobe  of  the  right  hemisphere  upwards,  and  the  anteri- 
r  surface  of  the  middle  lobe  backwards.  The  right  motor  oculi 
lerve  was  absorbed.  Within  the  cranium,  the  right  optic  nerve 
'ras  smaller  than  the  left ;  within  the  orbit,  merely  its  neurilema 
emained.  The  right  nostril  was  obliterated  by  the  pressure  of  the 
umour.  The  frontal  and  maxillary  sinuses  on  the  right  side 
/ere  full  of  puriform  mucus.  This  patient  had  all  along  refused 
3  submit  to  any  operation. 

'  Treatment.  In  the  early  stage,  leeching  may  be  tried,  on  the 
ame  principle  which  we  follow  when  we  endeavour  to  reduce  a 
uspected  scirrhus  of  the  mamma.     A  succession  of  blisters  mav  be 


80 

applied  to  the  forehead  and  temple.     Iodine,  and  other  solvents  and 
sorbefacients,  may  be  used. 

If  such  means  are  ineffectual  in  I'educing  the  swelling,  extirpa- 
tion of  the  gland  is  our  only  other  resource,  and  ought  to  be  em- 
ployed. It  will  be  in  vain  to  think  of  extirpating  an  enlarged 
lachrymal  gland  from  beneath  the  upper  eyehd,  unless  the  eyelids 
are  first  of  all  disjoined  at  their  outer  angle,  by  an  incision  car- 
ried outwards  through  the  skin  and  orbicularis  palpebrarum, 
towards  the  temple.  If  this  be  done,  the  upper  lid  may  be  raised, 
and  the  conjunctiva  exposed  and  divided,  so  as  to  bring  the  en- 
larged gland  into  view\  The  mode  of  extirpation,  however, 
which  has  generally  been  adopted,  is  to  cut  down  directly  over 
the  tumour,  through  the  upper  eyelid,  and  parallel  to  the  edge  of 
the  orbit.  The  gland  is  then  to  be  laid  hold  of  vrith  a  hook, 
dragged  out  of  its  situation,  separated  cautiously  from  its  connex- 
ions, and  removed.  After  the  bleeding  has  ceased,  the  edges  ol 
the  wound  are  to  be  brought  together  with  two  or  three  stitches, 
and  a  few  strips  of  court-j)laster.  Neither  is  the  vision  nor  the 
position  of  the  eye  restored  immediately  after  extirpating  the  gland. 
Weeks,  or  even  months,  may  be  requisite  before  these  objects  are 
accomphshed  ;  and  although  the  malposition  of  the  eye  is  always 
lessened  in  time,  if  not  entirely  removed,  vision  may  never  be  re- 
stored. The  moisture  and  lubricity  of  the  conjunctiva  remaining 
unaffected  after  extirpation  of  the  lachrymal  gland,  has,  it  is  prob- 
able, given  rise  to  the  statement  of  some,  that  the  patient  continues 
capable  of  weeping. 

Cases  of  extirpation.  Guerin,*  Warner,t  and  TraverS;+  ap- 
pear to  have  performed  this  operation  ;  but  the  details  which  thej 
have  given  on  the  subject,  are  comparatively  few,  and  hence  ar 
additional  degree  of  interest  which  has  attached  itself  to  the  twc 
cases  recorded  by  Mr.  Todd,  and  Dr.  O'Beirne.  These,  therefore 
I  shall  quote,  along  with  a  case  by  Mr.  Lawrence,  and  anothei 
by  Daviel. 

Case  1.  Mr,  Todd's  patient  was  a  woman  of  70  years  of  age 
The  lachrymal  gland  formed  a  large  irregular  tumour,  occupying 
the  upper  part  of  the  orbit,  projecting  more  than  half  an  inch  be 
yond  the  superciliary  ridge,  and  covered  by  the  upper  eyelid 
which  was  so  stretched  upon  it  as  to  render  the  knotty  eminence: 
on  its  surface  very  conspicuous.  The  tumour  was  extremely  hard 
It  w^as  moveable  to  a  slight  extent,  in  a  transverse  direction  only 
The  globe  of  the  eye  was  not  enlarged,  but  it  had  been  protrudec 
by  the  tumour,  and  was  so  low  upon  the  cheek  that  the  corne; 
was  nearly  on  a  line  with  the  edge  of  the  ala  nasi.  The  lowe 
eyelid  was  everted,  and  appeared  dragged  down  with  the  globe 
the  conjunctiva  much  thickened,  and  cheraosed.     The  transparen 

*  Richerand,  Xosographie  Chirurgicale.     Tome  ii.  p.  31.     Paris,  1808. 

t  Cases  in  Surgen-,  p.  1C8.     London,  1784. 

t  Synopsis  of  the  Diseases  of  the  Eye,  p.  2"28.     London,  1320. 


81 

cy  of  the  cornea  was  slightl}''  obscured.  There  was  no  apparent 
disease  of  the  interior  of  the  eye.  Vision  was  destroyed  by  the 
pressure  of  the  tumour.  The  pains  were  severe  and  lancinating, 
extending  from  the  tumour  to  the  globe  of  the  eye,  and  were  ac- 
companied with  a  sensation  of  heat,  and  a  frequent  discharge  of 
scalding  tears.  The  sufferings  of  the  patient  were  most  severe  at 
night,  and  she  was  almost  entirely  deprived  of  sleep  ;  notwith- 
standing which,  her  general  health  was  not  much  impaired,  and 
her  appetite  for  food  was  good.  She  attributed  the  disease  to  a 
blow  wliich  she  had  received  on  the  eye  about  7  years  before; 
from  which  period  she  had  been  subject  to  frequent  discharges  of 
tears  from  that  eye,  but  had  suffered  no  other  inconvenience  until 
a  year  before  coming  under  Mr.  T.'s  care,  when  the  tumour  began 
to  project  under  the  temporal  extremity  of  the  eyebrow.  At  first 
she  had  no  pain  or  headach  ;  but  as  the  tumour  increased  these 
symptoms  set  in,  and  had  ultimately  become  so  severe  that  she 
was  anxious  to  undergo  any  operation  which  held  out  a  prospect 
of  relief.  In  consultation  with  Mr.  Carmichael,  Mr.  T.  determined 
that  an  attempt  should  be  made  to  extirpate  the  diseased  gland 
alone,  and  in  the  event  of  that  being  found  impracticable,  either 
from  extent  of  attachments,  or  deep-seated  disease,  the  expediency 
of  removing  all  the  contents  of  the  orbit  was  fully  acceded  to  ; 
the  intense  sufferings  of  the  patient,  the  probable  nature  of  the 
disease,  and  the  useless  state  of  the  eye,  appearing  to  render  this 
an  indispensable  alternative. 

The  patient  having  been  placed  on  her  back  on  a  table,  with 
her  head  a  little  elevated  and  secured  by  the  assistants,  a  transverse 
incision  was  made  through  the  integuments,  nearly  parallel  to  the 
superior  margin  of  the  orbit,  from  one  extremity  of  the  tumour  to 
the  other.  Having  cut  through  the  orbicularis  palpebrarum  and 
the  ligamenlum  tarsi,  Mr.  T.  exposed,  by  a  careful  dissection,  the 
entire  anterior  surface  of  the  gland.  Being  firmly  wedged  into  the 
orbit,  it  was  not  without  difficulty  that  the  handle  of  the  scalpel 
was  introduced  between  the  gland  and  the  superciliary  ridge  in  or- 
der to  detach  it  from  the  orbitary  process  of  the  frontal  bone.  The 
surface  of  ihe  gland  next  the  eye  was  irregularly  lobulated,  and  the 
lobes  had  insinuated  themselves  amongst  the  muscles  and  other 
contents  of  the  orbit,  so  as  to  render  their  disentanglement  extremely 
difficult  and  hazardous.  By  cautiously  tearing  their  cellular  at- 
tachments with  the  end  of  the  finger,  the  handle  of  the  knife,  and 
the  blunt  extremity  of  a  director,  and  by  cutting  on  the  finger  with 
a  probe-pointed  bistoury  some  firm  membranous  bands,  which 
could  not  be  easily  broken,  Mr.  T.  succeeded  in  extracting  the  en- 
tire tumour.  On  a  careful  examination  no  farther  disease  could  be 
detected  in  the  orbit,  and  as  no  bleeding  occurred,  (he  globe  of  the 
eye  was  gently  pressed  towards  its  natural  situation,  the  wound 
dressed,  the  parts  supported  with  a  compress  and  bandage,  and  the 
i  patient  laid  in  bed,  with  strong  injunctions  to  observe  the  strictest 


82 

quiet.  The  extirpated  gland  was  much  larger  than  a  walnut.  On 
the  surface  which  had  been  towards  the  eye,  it  presented  three  con- 
siderable eminences  or  lobes,  with  deep  fissures  between  them.  It 
was  almost  as  firm  as  cartilage,  and  more  elastic.  A  section  ex- 
posed several  small  cartilaginous  cysts,  which  contained  a  glairy 
fluid,  the  interspaces  consisting  of  a  firm  fatty  substance,  traversed 
by  a  few  membranous  bands.  Two  hours  after  the  operation,  an 
alarming  hccmorvhage  took  place,  which,  from  the  great  depth  at 
which  the  wounded  vessel  was  situated,  and  the  extensive  extrava- 
sation of  blood  into  the  loose  cellular  tissue  of  the  orbit,  was  with 
difficulty  suppressed  by  pressure  with  the  finger.  Dossils  of  lint 
were  then  introd'iced  into  the  wound,  and  the  bleeding  did  not  re- 
cur. The  pafienr  paesed  a  tranquil  night,  and  for  tbe  first  time 
during  many  Vvceks  enjoyed  refreshing  sleep.  On  the  following 
da}-,  the  appearance  cf  the  eye  and  surrounding  parts  was  by  no 
means  encouraging.  The  globe  was  protruded  from  the  orbit  as 
liiuch  as  before  the  operation,  by  large  coagula,  which  occupied  the 
situation  of  the  tumour ;  the  lids  were  affected  with  extensive  ecchy- 
mosis ;  tlev  were  livid  and  cold,  as  if  in  the  state  of  gangrene  ; 
and  the  cellular  tissue  of  the  conjunctiva  was  distended  with  effused 
blood.  ^Notwithstanding  these  unfavourable  appearances,  the  pa- 
tient had  experienced  inuch  relief  from  the  operation  ;  she  was  free 
from  acute  pain,  and  the  constitutional  excitement  was  inconsider- 
c.  jle.  In  the  course  of  a  few  days,  the  coagulated  blood  contained 
in  the  orbit  began  to  dissolve,  and  suppuration  was  soon  established. 
The  globe  of  the  eye  began  slowly  to  return  into  its  natural  situa- 
tion, and  the  conjunctiva  and  skin  of  the  eyelids  to  assume  their 
health}-  appearance.  On  the  12(.h  day  after  the  operation,  the  im- 
provement in  the  position  of  the  eye  was  quite  evident ;  but  it  was 
found  impossible  to  prevent  the  eversion  of  the  lower  eyelid,  in  con- 
sequence of  a  thickened  fold  of  the  conjunctiva,  which  extended 
between  it  and  the  globe.  To  this  fold  the  nitrate  of  silver  had 
been  frequently  applied  without  any  benefit ;  3Ir.  T.  therefore  re- 
moved it  by  excision,  and  was  immediately  enabled  to  replace  the 
lid,  which  showed  no  farther  tendency  to  become  everted.  From 
this  period  the  patient's  recovery  was  uninterrupted,  and  she  was 
discharged  without  any  return  of  disease.  Yision  remained  totally 
lost,  the  pupil  greatly  contracted,  the  position  of  the  eyeball  almost 
natural.* 

Case  2.  A  man,  a.ged  22  years,  strong  and  athletic,  came 
under  the  care  of  Dr.  O'Beirne,  with  considerable  deformity  and 
imperfect  vision  of  the  right  eye.  The  globe  projected  more  by  its 
semi-diameter  than  the  sound  eye,  yet  it  was  covered  almost  entirely 
by  the  upper  eyehd  which  hung  loosely  over  it,  as  if  paralyzed  ;  the 
pupil  was  dilated  and  insensible  to  light,  the  cornea  was  turned 
towards  tha  nose,  and  the  puncta  lachrymalia  were  patulous.     The 

*  Dublin  Hospital  Reports.     Vol.  iii.  p.  419,     Dublin,  1822- 


83 

upper  and  outer  part  of  the  orbit  was  occupied  by  a  tumour,  the 
outline  of  which  could  not  be  distinctly  traced,  but  to  its  growth 
were  attributed  the  protrusion  of  the  eye  and  impaired  vision. 
The  patient  suffered  considerable  pain  of  the  right  side  of  the  head 
and  face,  and  much  irritation  and  watering  of  the  eye  were  pro- 
duced by  cold  air,  or  particles  of  dust.  All  objects  appeared  to  him 
double ;  and  in  endeavouring  to  reach  any  object,  his  hand,  or  foot 
generally  fell  short  of  it,  so  much  as  to  prevent  him  from  working 
even  as  a  labourer.  About  two  years  before  coming  under  Dr. 
O'B.'s  care,  he  perceived  first  of  all  sparks,  and  occasionally  mists, 
before  his  eyes,  with  sharp  intermitting  pains  in  the  right  side  of 
his  head  and  face  ;  in  about  a  year,  a  slight  prominence  and  inver- 
sion of  the  globe  were  observed ;  and  from  that  period,  the  symp- 
toms gradually  proceeded  to  the  state  already  described.  It  was 
decided  in  consultation,  that  the  tumour  should  be  removed,  but  it 
was  not  even  suspected  that  the  lachrymal  gland  was  the  part 
affected.  The  operation  was  begun  by  an  incision  through  the 
integuments  of  the  upper  eyelid,  extending  from  the  inner  to  the 
outer  angle.  The  obicularis  palpebrarum  being  next  divided,  some 
portions  of  adipose  substance  which  presented  were  removed.  Dr. 
O'B.  then  introduced  his  finger,  and  at  once  discovered  that  the 
disease  was  an  enlarged  and  indurated  lachrymal  gland.  The 
anterior  surface  of  the  tumour  was  exposed  by  dissection,  and  it  was 
finally  removed  by  cautiously  working  with  the  nail  of  the  little 
finger,  for  it  was  not  considered  safe  to  introduce  a  knife  into  t'a 
back  of  the  orbit.  The  surface  of  the  extirpated  gland  was  gran- 
ular, and  of  a  pink  colour.  It  was  enlarged  to  at  least  six  times 
its  natural  size.  When  cut  into,  it  presented  a  hard,  membranous, 
or  rather  cartilaginous  centre,  from  v^hich  septa  passed  to  the  cir- 
cumference. No  sanies  could  be  perceived.  On  the  tumour  being 
removed,  the  pupil  instantly  recovered  its  contractile  power,  and  the 
globe  retired  nearly  to  its  natural  situation.  Yision  too  was  iiVi- 
proved,  but  not  perfectl}^  restored.  Scarcely  any  hseniorrhage 
ensued,  and  the  wound  was  dressed  simply.^  With  the  exception. 
of  a  slight  erysipelas  of  the  scalp,  which  yielded  to  ihe  usual  reme- 
dies, the  patient's  recovery  was  uninterrupted;  and  the  wound  was 
completely  healed  on  the  fourteenth  day  after  ibe  operation.  At 
that  time,  vision  was  perfect,  all  uneasiness  had  subsided,  and  the 
eye  occupied  its  proper  place.  The  upper  eyelid,  however,  having 
continued  so  much  relaxed  as  to  obscure  a  great  part  of  the  cornea, 
a  camel's  hair  pencil,  dipped  in  sulphuric  acid  diluted  with  three 
parts  of  water,  was  drawn  in  the  line  of  the  cicatrice.  In  a  few 
days  a  slough  separated,  and  the  subsetjuent  cicatrization  of  the  ulcer 
contracted  the  lid  to  its  natural  state.  The  patient  continued  per- 
fectly well,  and  suffered  no  inconvenience  from  the  loss  of  the 
gland.* 

*  Dublin  Hospital  Reports.     Vol.  iii.  p.  426.     Dublin,  1832. 


84 

Case  3.  The  following  report  of  a  case  of  extirpation  of  the 
lachrymal  gland,  by  Mr.  Lawrence,  appeared  in  the  Lancet.* 
John  Clifton,  aged  24,  seven  years  before  his  admission  to  the 
London  Ophthalmic  Infirmary,  received  a  violent  blow  on  the  left 
upper  lid,  near  the  external  angle  of  the  orbit.  This  was  followed 
by  considerable  swelling,  which  gradually  subsided.  Two  months 
afterwards  the  lid  again  swelled,  with  considerable  pain,  which 
lasted  for  about  a  month.  The  pain  then  went  off  entirely,  but 
the  swelling  continued.  There  was  a  constant  profuse  watery  dis- 
charge, considerably  increased  by  exposure  to  the  air.  The  globe  of 
the  eye  became  gradually  protruded  from  the  orbit,  with  loss  of  all 
useful  vision.  A  fortnight  before  his  admission,  the  eye  inflamed, 
and  became  very  painful.  There  was  general  fulness  of  the  upper 
lid,  which  was  more  particularly  swelled,  and  broader  than  natural, 
near  the  external  angle.  The  globe  and  the  lower  lid  were  pushed 
downwards  and  inwards  to  about  half  way  between  the  orbit  and 
the  nose  ;  but  although  the  globe  was  quite  out  of  its  socket,  the 
lids  were  so  extended  as  to  cover  it  completely.  There  was  con- 
siderable inflammation  of  the  external  tunics,  a  broad  red  zone  in 
the  sclerotic  round  the  cornea,  with  general  dulness,  and  a  small 
ulcer  of  the  latter.  A  hard  unyielding  tumour,  tuberculated  on  its 
surface,  projected  a  little  beyond  the  margin  of  the  orbit,  at  its  upper 
and  outer  part.  Mr.  L.  thought  it  doubtful  whether  or  not  this 
tumour  "was  moveable  upon  the  bone.  Mr.  Tyrrell  considered  it 
not  moveable,  and  therefore  did  not  recommend  its  extirpation. 
The  patient  was  cupped,  bled  with  leeches,  and  purged.  Mr. 
Wardrop  was  consulted,  and  after  convincing  himself  that  the 
tumour  had  not  any  immediate  connexion  with  the  bone,  he 
strongly  advised  its  removal  by  an  operation,  which  3Ir.  L.  accord- 
ingl}'  peiformed.  As  the  swelling  obviously  filled  a  large  portion 
of  the  orbit,  and  probably  extended  deeply  into  that  cavity,  it  was 
desirable  to  have  ample  room,  and  the  external  incisions  were 
therefore  free.  The  first,  of  about  3  inches  in  length,  extended 
from  the  temple,  along  the  fold  of  the  upper  lid,  to  the  root  of  the 
nose  ;  the  second  of  2  inches,  passed  perpendicularly  over  the  upper 
and  outer  part  of  the  orbit  and  forehead,  to  meet  the  first  at  right 
angles.  It  was  found  necessary  to  moke  a  third  incision,  from  the 
first  towards  the  anterior  root  of  the  zygoma.  By  turning  aside 
the  flaps  produced  by  this  crucial  incision,  the  seat  of  the  tumour 
was  completely  exposed.  No  other  difficulty  was  experienced, 
except  that  inseparable  from  the  size  and  hardness  of  the  swelling,  its 
deep  extent  backw"ards,  and  close  contact  with  the  orbit  and  its  con- 
tents :  its  surrounding  connexions  were,  however,  merely  cellular. 
The  tumour  consisted  of  the  lachrymal  gland,  increased  to  the  size 
of  a  large  walnut,  and  of  the  most  compact  homogeneous  structure ; 
having  a  firmness  of  texture  approaching  to  that  of  cartilage,  a  light 

•  Vol.  X.  p.  159.    Locdon,  1826. 


85 

rellow  tint,  and  at  one  part  an  appearance  of  white  radiating  fibres. 
Altogether  it  much  resembled  the  firmest  part  of  a  scirrhous  breast. 
During  the  operation,  a  large  quanti'iy  of  blood  was  lost,  and,  as  it 
illed  the  deep  cavity  left  by  removing  the  tumour,  its  source  could 
lot  be  discovered.  The  patient  w^^as  left  quiet,  in  the  hope  that 
he  bleeding  would  cease ;  it  continued,  however,  fieely,  for  more 
han  half  an  hour,  rendering  the  patient  very  faint.  An  artery 
,vas  then  secured.  The  incisions  were  approximated  by  5  small 
;ilk  ligatures,  and  3  narrow  slips  of  adhesive  plaster  ;  and  the  parts 
vere  constantly  covered  wnth  a  wet  rag.  By  the  following  day, 
he  wounds  having  united  by  adhesion,  the  stitches  and  straps 
vere  removed.  The  eye  (says  the  report)  had  receded  to  its  natu- 
al  position,  and  the  inflammation  of  the  sclerotic  had  ceased, 
i^ourteen  days  afterwards,  the  cornea  had  nearly  recovered  its 
ransparency,  vision  was  much  improved,  the  eye  moved  freely,  and 
ts  surface,  with  that  of  the  lids,  was  as  moist  as  usual. 

Case  4.  A  Medical  Journal  published  at  Bourdeaux  in  January 
1829,  contains  an  account  of  some  cases  of  extirpation  of  the  lach- 
•ymal  gland,  performed  many  years  before,  by  Daviel.  One  of 
hese  cases  is  that  of  a  peasant,  63  years  of  age,  who,  eleven  years 
oefore  he  consulted  Daviel,  had  received  a  blow  on  the  upper  part 
)f  the  right  orbit,  for  which  fomentations  and  other  remedies  were 
employed  ;  notwithstanding  which  the  eye  became  projected  from 
:he  orbit  so  as  to  produce  considerable  deformity,  and  to  impede  its 
"unctions.  On  careful  examination,  Daviel  discovered  a  fistulous 
Dpening,  about  a  line  in  width,  which  penetrated  the  orbit.  By 
introducing  a  probe,  an  extremely  hard  body  was  felt  between  the 
^lobe  of  the  eye  and  the  bone,  which  was  likewise  discovered  to  be 
carious  at  the  upper  part  of  the  orbit.  A  director  was  introduced 
into  the  sinus,  and  an  incision  made  tiirough  the  upper  eyelid,  from 
the  outer  and  upper  angle  of  the  orbit  to  within  the  8th  of  an  inch 
of  the  inner  and  upper  angle.  By  this  incision  the  ball  of  the  eye 
and  the  caries  of  the  orbit  were  exposed,  and  several  pieces  of  dis- 
eased bone  removed.  Nearly  an  ounce  of  grumous  matter  escaped, 
which  had  been  contained  in  a  strong  cyst,  and  which,  as  well  as 
the  lachrymal  gland,  was  removed.  The  gland  was  nearly  as 
large  as  a  pigeon's  egg.  A  small  fatty  tumour  was  also  removed  ; 
after  which  the  eye  was  easily  restored  to  its  natural  situation  ;  and 
the  strabismus,  which  had  been  present  before  the  operation,  dis- 
appeared. The  wound  was  simply  dressed,  except  that  little  dos- 
sils of  charpie  dipped  in  tincture  of  myrrh  and  aloes  were  applied  to 
those  points  of  bone  which  were  exposed.  In  less  than  a  month 
the  patient  was  radically  cured  ;  the  eye  being  as  moist  as  the 
other,  and,  (if  the  narrator  of  the  case  can  be  credited),  capable  of 
weeping,  as  if  the  lachrymal  gland  had  been  present.* 

*  London  Medical  Gazette.     Vol.  iii.  p.  523.     London,  1829. 


86 


SECTION  VI.— LACHRYMAL  TUMOUR  IN  THE  LACHRYMAL  GLAND. 

This  disease  appears  lo  have  been  for  the  first  time  accurately 
described  by  Professor  Schmidt. 

It  consists  in  a  collection  of  thin  fluid  in  the  situation  of  the  lach- 
rymal gland.  This  fluid  is  supposed  to  be  tears,  and  the  cyst  in 
which  it  collects  to  be  originally  nothing  more  than  one  of  the  cells 
of  the  cellular  membrane,  serving  to  hold  together  the  acini  oi 
grains  of  which  the  lachrymal  gland  is  composed.  Whether  this 
is  really  a  lachrymal  tumour,  or  merely  a  common  encysted  tumour 
situated  in  the  lachrymal  gland,  or  at  least  closely  connected  with 
it,  is  a  matter  of  little  consequence.  Were  we  certain  that  it  was 
the  latter,  we  should  not,  of  course,  make  it  the  subject  of  a  sepa- 
rate section,  but  class  it  under  the  head  of  orbital  tumours. 

That  this  is  a  rare  disease  may  be  concluded  from  the  fact  that 
Schmidt  relates  only  two  cases  of  it ;  and  that  Beer  had  seen  only 
three  cases.  In  one  of  Beer's  cases,  the  diagnosis  became  com- 
pletely^ evident  only  after  death.  In  the  tumour,  Beer  found  a  small 
quantity  of  fluid,  which  he  does  not  hesitate  to  call  tears,  and  whicl; 
was  thin,  clear,  sharp,  and  saltish  to  the  taste.  In  the  second  case. 
Beer  opened  the  tumour  during  life ;  the  fluid  discharged  was  yel- 
lowish like  serum,  but  so  acrid  that  it  immediately  caused  a  small 
vesicle  when  applied  to  the  tongue.  In  Beer's  third  case,  he  was 
merely  consulted  in  the  commencement  of  the  disease. 

Schmidt  called  this  disease  hydatid  of  the  lachrymal  gland  ;  but 
as  there  is  not  the  least  reason  to  suppose  the  C3^st  in  the  present 
case  to  be  alive,  it  is  less  ambiguous  to  name  this  disease,  lachrymal 
tumour  in  the  lachrymal  gland.  Indeed,  Schmidt's  own  hypothesis 
of  the  origin  of  the  cyst  is  quite  inconsistent  with  the  assumption, 
that  this  disease  is  at  all  analogous  to  those  parasitical  zoophytes, 
which  are  well  known  under  the  name  of  hydatids.  He  supposes 
that  a  single  cell  of  the  cellular  membrane  connesiing  the  acini  of 
the  lachrymal  gland  becomes  distended,  and  filled  with  tears,  and 
that  this  is  the  origin  of  this  disease.  It  is  not  easy  to  explain  how 
this  cell  should  afterwards  become  detached,  so  as  to  form  a  cyst, 
which  anay  be  sometimes  extracted,  as  if  quite  unadherent  to  the 
surrounding  parts  ;  for  to  tell  us,  as  Schmidt  has  done,  that  the 
distended  cell  presses  aside  the  surrounding  cellular  membrane,  so 
as  to  form  a  sort  of  capsule  for  itself,  and  that  between  this  capsule 
and  the  proper  membrane  of  the  cell  an  interstitial  fluid  is  after- 
wards effused,  is  to  indulge  entirely  in  conjecture. 

Symptoms.  The  development  of  lachrymal  tumour  in  the  lach- 
rymal gland  is,  in  some  cases  at  least,  very  rapid ;  and  its  conse- 
quences are  not  merel}^  distressing,  but  dangerous.  One  of 
the  most  striking  symptoms  attended  this  tumour  is  protrusion  of 
the  eye.  It  is  pushed  forward  fioni  the  orbit,  and  inward,  toward 
the  nose.  I  have  already  had  occasion  to  mention  that  protrusion 
of  the  eye  is  called  exophthalmos,  if  there  is  no  other  change  than 


87 

merely  the  change  of  place,  but  that  if  there  be  inflammatory  dis- 
organization of  the  whole  globe  of  the  eye  along  with  the  protrusion, 
this  state  is  called  exophthalmia. 

When  this  disease  is  attended  with  exophthalmos,  the  following 
are  the  symptoms.  The  patient,  perhaps  perfectly  well  in  every 
other  respect,  complains  of  obtuse,  deep-seated  pain  in  the  orbit. 
The  pain  is  as  if  something  behind  the  eyeball  were  pushing  it  out 
of  its  socket.  It  is  felt  m.ost  when  the  patient  moves  his  eye  in 
difl'erent  directions,  and  especially  when  he  turns  it  towards  the 
temple.  It  daily  increases.  Nothing  unnatural  in  the  form  nor 
in  the  texture  of  the  eye  nor  eyelids  is  as  yet  discernible.  By  and 
by,  there  is  added  to  the  pain  behind  the  eye,  a  feeling  of  tension 
both  in  the  orbit  and  over  the  side  of  the  head  ;  and  the  eyeball  is 
now  observed  to  be  somewhat  protruded  from  the  orbit  and  towards 
the  nose.  Some  few  individual  blood-vessels  excepted,  it  is  not  red. 
The  patient  has  a  feehng  of  dryness  in  the  eye.  He  cannot  move 
the  eye  without  great  aggravation  of  the  pain,  and  a  sensation  of 
sudden  flashes  of  light  in  the  eye.  At  last,  he  is  totally  deprived 
of  the  power  of  moving  it.  When  he  regards  objects  with  the  pro- 
truded eye,  he  sees  them  disfigured.  If  he  looks  with  both  eyes,  he 
sees  objects  double,  as  the  protruded  eye  stands  no  longer  in  the 
natural  axis  of  vision.  The  more  that  the  lachrymal  tumour  pushes 
the  eyeball  out  of  the  orbit,  vision  becomes  the  weaker  and  more 
disturbed.  In  proportion  as  the  disease  advances,  the  patient  loses 
his  appetite,  and  is  deprived  more  and  more  of  sleep.  The  hemi- 
crania  becomes  uninterrupted,  by  day  and  night.  Vision  is  entirely 
lost.  The  eye  is  so  much  protruded,  that  it  rests  in  some  measure 
upon  the  cheek.  The  eyelids  lose  all  power  of  motion,  the  upper 
one  being  firmly  extended  over  the  protruded  eye.  The  patient 
betrays  a  constant  incUnation  to  cover  the  eye  with  the  eyelids,  and 
at  every  attempt  to  do  so  the  eyeball  is  rolled  by  the  action  of  the 
obliqui  towards  the  nose.  A  resisting  hardness  is  felt  with  the  fin- 
ger at  the  temporal  angle  of  the  eye,  between  the  protruded  eyeball, 
and  the  external  edge  of  the  orbit.  The  eye  becomes  sullied  and 
dusky.  If  nothing  is  done  to  relieve  the  symptoms,  coma  and  death 
are  the  consequences. 

Should  this  disease  be  combined  with  exophthalmia,  besides  ob- 
tuse, deep-seated,  and  constantly  increasing  pain  in  the  orbit,  there 
is  pain  in  the  eyeball  itself ;  and  whereas,  in  the  former  case,  the 
eye,  though  protruded  by  the  growing  tumour,  preserves  its  ordina- 
ry size,  in  the  present  case  it  is  rapidly  enlarged,  and  destroyed  by 
inflammation.  It  goes  on  to  suppuration,  and  unless  opened  by 
the  knife,  bursts,  discharging  blood,  and  ichorous  matter.  The 
membranes  do  not  collapse  after  this  evacuation,  but  the  eyeball 
I  continues  to  project  from  the  orbit,  a  fleshy  formless  mass,  proving 
[how  much  its  organization  had  suffered  by  the  processes  of  inflam- 
'  mation  and  suppuration.  The  pain  in  the  burst  eye,  and  in  the 
half  of  the  head,  continues,  the  patient  is  deprived  of  sleep  and  ap- 


88 

petite,  and  the  lymphatic  glands  about  the  face  become  enlarged. 
Should  a  patient  present  himself  with  such  symptoms,  we  shall  na- 
turally be  led  to  suspect  the  existence  either  of  this  disease,  or  of 
some  other  disease  of  the  lachrymal  gland,  and  our  suspicions  will 
be  confirmed  if  we  find  a  resisting  hardness  between  the  destroyed 
eyeball  and  the  external  edge  of  the  orbit.  This  symptom,  how- 
ever, may  be  detected,  it  is  likely,  at  a  much  earlier  period  of  the 
disease.  Could  we  dare  to  draw  a  conclusion  upoa  this  point  from 
the  few  cases  of  lachrymal  tumour  on  record,  we  should  say  that; 
this  disease  is  more  apt  to  terminate  fatally  when  attended  by  ex- 
ophthalmos, than  when  accompanied  by  exophthalmia.  In  neg- 
lected cases,  however,  of  lachrymal  tumour  with  exophthalmia,  the 
disorganization  spreads  to  the  bones  of  the  orbit,  and  at  last  the 
brain  itself  l>ecoming  affected,  death  puts  an  end  to  the  patient's 
sufferings.  This  was  the  termination  of  one  of  the  three  cases  ob- 
served by  Beer. 

Treatment.  The  radical  cure  of  lachrymal  tumour  in  the  lach- 
rymal gland,  would  consist,  no  doubt,  in  extirpating  the  tumour 
before  the  eye  became  protruded,  at  least  lo  any  considerable  ex- 
tent, from  the  orbit ;  but  at  ihh  period,  we  cannot  distinguish  the 
disease  with  sufScient  certainty.  Even  had  we  the  means  of  de- 
termining that  the  commencing  exophthalmos  arose  from  this  dis- 
ease, could  we  extirpate  this  vesicular  sweUing  without  removing 
also  the  gland  in  which  it  was  situated? 

A  palliative  treatment  will  generally  be  adopted,  by  the  employ- 
ment of  which  we  may,^  on  the  one  hand,  save  the  life,^  and,  on  the 
other,  the  eye  of  the  patient.  It  may  even  happen  that  by  the 
early  employment  of  this  palliative  cure,  we  may  be  fortunate 
enough  to  cure  the  disease  completely.  No  hope  of  this,  however, 
need  be  entertained,  if  the  eyeball  be  already  protruded  from  the 
orbit,  the  power  of  vision  lost,  the  eyeball  beginning  to  appear 
dusky  and  lifeless^  or  if  it  be  violently  inflamed,  and  in  part  disor- 
ganized. 

The  palliative  cure  consists  in  puncturing  the  tumour,  and  evac- 
uating the  accumulated  fluid.  This  should  be  done,  if  practicable, 
from  under  the  upper  eyelid,  with  a  lancet  or  delicate  histouri  radtc 
directed  towards  the  seat  of  the  lachrymal  gland.  Should  the  tU' 
mour  return  after  the  healing  of  the  wound,  the  operation  must 
be  repeated.  I  should  think  any  attempt  to  keep  the  wound  open, 
and  the  tumour  perpetually  empty,  by  the  introduction  of  a  bougie 
or  other  foreign  body,  out  of  the  question,  if  the  incision  were  made 
from  under  the  upper  eyelid.  But  if  the  protrusion  of  the  eye  were 
such  that  the  upper  eyelid  was  firmly  stretched  over  the  eyeball, 
and  that  no  instrument  could  be  passed  between  them,  the  tumoui 
would  require  to  be  opened  through  the  upper  eyelid,  and  the  wounc 
might  be  afterwards  kept  open  by  a  bit  of  catgut,,  so  as  to  give  exit 
to  any  reaccumulating  fiuicf,  and  perhaps  cause  a  radical  cure. 

That  through  the  openings  wherever  it  be  made,  the  cyst  of  the 


89 

umour  shall  be  extracted,  cannot  certainly  be  regarded,  a  'priori, 
IS  likely  to  happen  ;  yet  this  actually  took  place  in  one  of  Schmidt's 
)ases. 

Cases.  As  the  present  is  a  rare  and  interesting  disease,  I  am 
nduced  to  lay  before  the  reader  the  particulars  of  the  two  following 
:ases  related  by  Schmidt. 

Case  1.  A  private  soldier,  aged  26  years,  of  a  firm  and  corpu- 
ent  make,  from  fatigue  and  exposure  to  cold,  became  ill  with  fever, 
n  the  end  of  November,  1800.  According  the  history  of  the  case, 
le  had  a  slight  typhus,  which  yielded  to  the  use  of  the  proper 
neans,  so  that  he  left  the  hospital  in  the  beginning  of  January 
801,  and  set  off  for  his  regiment.  Already,  some  days  before  he  left 
he  hospital,  he  had  an  obtuse,  deep-seated  feeling  of  pressure  in  his 
ye ;  but  he  set  himself  out  against  it,  and  said  nothing  of  it  to  his 
oedical  attendant.  He  was  about  8  days  with  his  regiment,  when 
le  observed  that  this  obtuse,  deep-seated  pain  grew  more  constant 
nd  more  troublesome.  But  as  he  could  discover  nothing  wrong 
bout  his  eye,  and  saw  perfectly  well,  he  let  matters  rest  as  they 
i^ere.  In  the  beginning  of  the  third  week  the  feeling  of  pressure 
lecame  violent,  he  felt  pain  with  tension  in  the  eye  itself,  and  in 
tie  corresponding  half  of  the  head  ;  the  eye  became  red  and  dry, 
nd  began  to  project;  he  frequently  had  the  sensation  of  fiery 
pectra,  and  at  times  his  sight  failed  him.  About  this  time,  he  be- 
an to  sleep  but  little.  With  these  symptoms,  he  was  unable  to 
erform  his  duty  as  a  soldier.  The  medical  officer  to  whom  he 
f/as  presented,  ordered  the  application  of  a  moist  warm  poultice, 
l^he  case  became  evidently  worse  from  day  to  day.  With  the  be- 
inning  of  the  fourth  week,  the  hemicrania  and  pain  in  the  eye 
ecame  furious,  day  and  night,  so  that  he  could  not  get  a  moment's 
eep  ;  the  eye  protruded  completely  from  its  socket,  so  that  it  was- 
ien  from  the  other  side  over  the  root  of  the  nose  ;  it  was  shghtly 
;d,  but  not  swollen,  moist  and  slippery,  but  deprived  of  sight, 
^he  appetite  for  food,  which  had  continued  till  now,  was  lost, 
^he  patient's  restlessness  rose  to  the  extreme.  In  this  state,  he 
■as  brought  to  the  Military  Hospital  of  Vienna,  on  the  4th  Febru- 
ry.  Early  on  the  5th,  Schmidt  saw  him  for  the  first  time.  Be- 
;des  the  above-mentioned  symptoms,  he  found  the  patient  affected 
'ith  spasm  of  the  superior  oblique  muscle,  whereby  the  eye  was 
Very  instant  drawn  more  out  of  the  orbit  and  towards  the  nose, 
["■he  eyelids  were  not  in  the  least  swollen,  but  quite  pushed  aside 
lom  the  eye.  Schmidt  felt  distinctly  a  resisting  hardness  in  the 
j  mporal  angle  of  the  orbit.  He  declared  before  those  who  attended 
|ie  visit,  that  the  disease  was  seated  in  the  orbit,  and  that  it  was 
fobably  a  steatomatous  tumour  for  which  nothing  decisive  could 
[i  undertaken.  Opium  internally  and  externally,  warm  poultices 
jVer  the  eye  and  head,  nothing  could  check  the  fury  of  the  pain. 
1  arly  on  the  6th,  Schmidt  found  the  patient  in  the  same  state,  only 
lat  the  eye  was  no  longer  lively,  but  dusky  and  somewhat  hke 
12 


90 

the  eye  of  a  ^ying  person,  while  the  appearance  of  the  sonnd  eye 
was  still  very  lively.  The  pulse,  the  respiration,  and  all  the  other 
functions,  were  not  in  the  least  altered.  Schmidt  determined  t( 
evacuate  the  eye,  next  day,  by  an  incision.  Towards  evening,  the 
patient  fell  into  a  state  of  sopor,  became  insensible,  discharged  his 
urine  and  fseces  involuntarily,  and  died  towards  midnight.  Or 
dissection,  the  veins  and  sinuses  of  the  brain  were  found  distendec 
with  blood.  There  was  no  accumulation  of  fluid  in  the  ventricles 
On  removing  the  orbitary  process'of  the  frontal  bone  without  injuring 
the  periosteum,  a  fluctuating  tumour  pressed  itself  upwards  fron 
the  temporal  angle  of  the  orbit.  On  continuing  the  dissection,  th 
muscles  of  the  eye,  optic  nerve,  and  other  nerves  of  the  orbit,  wer< 
observed  to  be  evidently  stretched  and  elongated,  and  the  opthalmi 
vein  appeared  varicose.  The  lachrymal  gland  was  smaller  thai 
usual,  and  in  connexion  with  it  lay  the  fluctuating  tumour.  Thi 
individual  acini  which  were  more  remote  from  the  tumour,  an 
were  dii'ected  towards  the  upper  eyelid,  were  larger  and  more  cc 
herent  :  v/hilst  those  acini  which  lay  upon  the  tumour  were  smal 
and  both  appeared  and  felt  more  loosely  scattered  than  natura 
The  tumour  was  in  diameter,  from  behind  foiivards,  the  length  c 
an  inch  ;  in  transverse  and  perpendicular  diameters  somewhat  lei 
than  an  inch.  It  pressed  itself  close  upon  the  external  segment  ( 
the  eyeball,  and  even  after  death  held  the  eyeball  out  of  the  orb 
and  towards  the  nose.  It  had  an  external  and  an  internal  cove 
ing.  The  external  consisted  of  thick  cellular  membrane.  Betwee 
this  and  the  internal  covering  was  a  quantity  of  interstitial  fluic 
The  internal  covering  w^as  very  fine,  semitransparent,  and  coi 
fcained  a  limpid  fluid.  The  external  membrane  could  not  be  easil 
separated  from  the  scattered  acini  of  the  lachrymal  gland.  Th 
internal  could  be  freel}^  extracted  from  the  external  covering.* 

Case  2.  A  young  country-woman  came  to  Yienna  in  Mb 
1802,  and  sought  Schmidt's  assistance.  Two  months  before,  si 
had  weaned  her  child  ;  and  immediately  after,  upon  being  e; 
posed  to  cold,  felt  violent  hemicrania  and  pain  in  the  eye.  Aft 
some  da3^s  the  eyeball  inflamed  severely,  became  swollen,  at 
pressed  itself  forwards  from  the  orbit.  When  the  woman  came 
Schmidt,  the  inflamed  eye  had  the  size  of  a  man's  fist,  the  cornc 
was  completely  destroyed  from  suppuration,  and  burst,  and  the  ir 
was  covered  by  a  new  and  wart-like  production,  so  that  it  was  wii 
difficulty  that  an  eye  could  be  recognised  in  this  formless  mass 
flesh.  Together  with  a  constant  pressing  pain  in  the  orbit,  ar 
continual  hemicrania,  Schmidt  found  all  the  symptoms  detailed 
the  former  case,  with  the  exception  of  the  spasmodic  motions  of  tl 
eyeball.  He  mentions  that  the  parotid  gland,  upon  the  same  sid 
was  swollen  towards  the  bi'anch  of  the  lower  jaw,  but  more  pr 
bably  the  sweUing  affected  one  of  the  lymphatic  glands  l5'ing  ov 

*  Schmidt  Qber  die  Krankheiten  des  Thranenorgans,  p.  90.    Wein,  1803. 


91 

ihe  parotid.  The  patient  was  admitted  into  the  hospital,  under 
Lhe  care  of  Mr.  Ruttorffer,  who  passed  a  stnall  flat  trocar  under  the 
upper  eyelid,  directing'  its  point  towards  the  fosi-a  kichryniahs, 
where  the  resistance  and  hardness  were  felt.  More  than  an  ounce 
Df  extremely  clear  fluid  was  immediately  discharged  through  the 
3anula.  The  canula  was  removed,  and  for  several  days  this  clear 
luid  issued  from  the  wound.  Some  hours  after  the  operation,  the 
lemicrania  suddenly  and  considerably  diminished,  and  from  day 
.0  day  the  exophthalmia  became  less.  On  the  14th  day  after  the 
operation,  a  whitish  streak  was  observed  in  the  wound,  resembling 
)us,  but  which  could  not  be  removed  with  a  httle  lint.  Mr.  R.  laid 
lold  of  this  with  a  pair  of  forceps,  and  drew  forth  the  cyst,  or  as 
5chmidt  chooses  to  call  it,  the  hydatid,  which,  as  represented  in 
lis  work,  must  have  measured  more  than  an  inch  in  diameter. 
\.fter  other  14  days,  the  woman  left  the  hospital,  the  exophthalmia 
jiaving  diminished  to  a  small  stump  of  an  eye.* 
)  From  the  state  to  which  the  eyeball  is  reduced  in  exophthalmia 
jiroceeding  from  this  disease,  it  is  not  unlikely  that  cases  of  this  sort 
lave  sometimes  been  taken  for  cancerous  affections,  and  the  eyeball 
)i'ith  the  cyst  extirpated.  An  instance  of  this  kind  we  find  in  the 
i^hilosophical  Transactions  for  1755,  related  by  Mr.  Spry,  surgeon 
)  t  Plymouth. 

[;  The  patient,  a  mariner's  wife,  complained  of  violent  pain  in  her 

(ift  eye,  and  sometimes  of  very  acute  pain  in  the  temple  of  the 

^ame  side,  with  some  defect  in  her  sight.     She  also  imagined  that 

I  er  eye  was  bigger  than  ordinary  ;  but,  upon  inspection,  it  appeared 

1 0  bigger  than  the  other.     The  cornea,  however,  became  less  trans- 

jarent,  and  the  pupil  greatly  dilated.     The  vessels  of  the  conjunc- 

[I  va  and  sclerotica  were  no  way  enlarged.     Bleeding,  blistering,  and 

urging,  proved  of  no  effect.     On  the  contrary,  the  cornea  became 

liore  opaque,  great  inflammation  of  the  conjunctiva  and  sclerotica 

psued,  and  an  apparent  prominence  of  the  whole  eye.     She  was 

^^ain  purged,  and  a  seton  put  in  the  neck  ;   but  the  symptoms  in- 

■eased.    She  became  still  more  miserable.    The  conjunctivabecame 

greatly  inflamed,  wath  eversion  of  the  upper  lid,  attended  with  great 

j  ;iin.    Mr.  S.  often  scarified  the  conjunctiva,  which  bled  plentifully, 

liQd  gave  her  eo^se  for  a  day  or  two.    He  also  took  blood  from  the  tem- 

pral  artery.     But  the  eye  being  greatly  enlarged,  and  of  so  terrible 

Q  appearance,  after  all  his  endeavours  for  eight  or  ten  months,  he 

idged  the  disease  to  be  carcinoma,  and  therefore  proposed  cutting 

jt  the  eye  as  the  only  remedy.     The  operation,  however,  was  de- 

rred  ;  till,  at  length,  the  eye  becoming  much  larger,  and  the  pain 

icreasing,  extirpation  was  had  recourse  to,  lest  the  bones  of  the 

•bit  might  become  caiious.     Mr.  S.  having  begun  his  incision 

)und  the  upper  part  of  the  tumour,   had  not  cut  deep,  when  a 

reat  quantity  of  fluid,  hke  lymph,  poured  out  upon  him  with  great 

:irce,  like  a  fountain.     The  tumour  subsided  a  good  deal ;  but  pur- 

*  Schmidt,  D.  94. 


92 

suing  the  operation,  he  found  a  large  cyst,  which  filled  the  whole 
orbit  behind  the  eye.  A  part  of  this  cyst  was  left  to  slough  off  with  j 
the  dressings.  The  whole  eye  being  cut  out,  he  filled  the  wound 
with  lint.  The  cure  went  on  with  success,  and  was  complete  in 
a  month.  On  examining  the  tumour  which  had  been  removed, 
the  eye  appeared  a  little  bigger  than  natural,  the  aqueous  humour 
not  so  clear  as  usual,  the  crystalline  less  sohd  and  transparent,  the 
vitreous  almost  reduced  to  a  liquid  state,  the  cyst  very  strong  and 
elastic,  with  a  cavity  sufficient  to  contain  a  large  hen's-egg.* 

There  can  be  little  doubt  that  this  was  a  misunderstood  case  o1 
lachrymal  tumour  in  the  lachrymal  gland,  or,  at  any  rate,  of  en- 
cysted orbital  tumour,  and  not  at  all  a  carcinoma. 


SECTION   VII. LACHRYMAL    TUMOUR    IN    THE      SUBCONJUNCTI 

VAL  CELLULAR  MEMBRANE. 

This  disease  resembles  considerably  in  its  nature  that  which  we 
have  last  considered.  Its  seat  seems  to  be  the  principal  difference 
for  the  tumour  described  in  the  last  section,  is  seated  in  the  sub 
stance  of  the  lachrymal  gland,  and  is  supposed  to  derive  the  fluic 
which  it  contains  from  the  gland  immediately  ;  while  the  presen 
disease,  seated  more  superficially,  is,  in  fact,  almost  immediatel; 
behind  the  conjunctiva,  and  derives  its  fluid,  according  to  Schmidt 
from  one  or  more  of  the  lachrymal  ducts.  Benedict  describes  it  a 
a  mere  dilatation  of  one  of  these  ducts.  The  tumour  in  the  disea& 
which  we  have  been  considering,  produces  a  series  of  the  most  dan 
gerous  symptoms,  long  before  it  comes  into  view  itself,  if  ever  i 
comes  into  view  ;  whereas,  the  present  disease,  from  its  superficia 
situation,  is  neither  productive  of  so  destructive  effects,  nor  can  i 
remain  so  long  concealed. 

Symptoons.  As  soon  as  it  has  reached  any  considerable  exteni 
the  present  disease  manifests  itself  by  the  following  symptoms.  1 
circumscribed,  very  elastic  swelling,  void  of  pain,  is  felt  immediatel; 
behind  the  upper  eyelid,  towards  the  temporal  side  of  the  orbit.  1 
the  tumour  has  already  reached  such  a  degree,  as  to  present  througl 
the  eyelid  the  size  of  a  hazel  nut,  and  if  we  press  upon  it  prett 
forcibly,  the  patient  feels  the  pressure  in  the  eyeball,  and  observe 
fiery  spectra  before  the  eye.  If,  at  the  same  time,  that  we  pres 
the  tumour  from  without,  we  raise  the  upper  eyelid,  and,  in  sora 
measure,  evert  it,  we  see  the  conjunctiva  project  in  the  form  of 
distended  sac,  in  which  we  discover  fluctuation.  When  the  ti 
mour  has  reached  the  size  of  a  pigeon's  egg,  the  motions  of  th 
eyeball  upwards  and  outwards  are  impeded  ;  yet,  when  we  rais 
the  upper  eyehd  in  the  manner  just  now  mentioned,  the  patient  i 
immediately  able  to  move  his  eye,  without  difficulty,  towards  th 
temple,  the  eyeball  retiring  behind  the  tumour,  pushing  it  and  th 
conjunctiva  still  more  forwards,  while  at  the  same  tune  the  fluctuf 

*  Philosophical  Transactions,  Vol.  xlix.  Part  1.  p.  18.  London,  1756. 


93 

tion  becomes  more  distinct.  From  extreme  distention,  the  conjunc- 
tiva, and  the  cyst  in  which  the  fluid  is  contained,  are  so  thin,  that 
the  pressure  we  employ  in  examining  the  disease,  seems  ahiaost 
sufficient  to  cause  the  rupture  of  the  tumour.  In  no  other  disease 
of  the  orbit,  or  of  the  eyelids,  do  we  observe  any  similar  symptoms. 
One  of  the  most  characteristic  marks  of  this  disease,  we  are  told, 
is  its  momentary  increase  when  the  patient  weeps. 

Causes.  It  is  supposed  that  the  proximate  cause  of  this  disease, 
is  the  termination  of  one  or  more  of  the  excreting  ducts  of  the  lach- 
rymal gland  in  the  loose  cellular  substance  under  the  conjunctiva ; 
that  one  of  the  cells  is  gradually  distended  by  the  accumulating 
tears,  and  at  last  forms  the  thin  sac,  the  projection  of  which  gives 
rise  to  the  symptoms  described.  That  this  is  the  real  nature  of  the 
case,  is  concluded  from  the  alleged  fact,  that  if  the  tumour  be  opened 
through  the  eyelid,  a  considerable  quantity  of  pure  tears  flows 
through  the  incision,  every  time  the  patient  weeps. 

Beer  met  with  this  disease  six  times  in  individuals  who  were 
between  4  and  14  years  of  age.  In  two  of  these  cases,  an  appa- 
rent exciting  cause  had  preceded  the  disease.  In  the  one,  the  cause 
was  a  violent  bruise  on  the  upper  edge  of  the  orbit,  from  the  spring- 
ing of  a  biUiard  ball.  In  the  other,  this  disease  arose  after  the  in- 
complete extirpation  of  an  encysted  tumour,  which  had  its  seat  at 
the  same  place. 

Treatment.  The  plan  of  cure  which  appears  the  most  rational 
for  this  disease,  is  to  evert  the  upper  eyelid,  or  if  that  cannot  be 
done  to  a  sufficient  extent,  to  separate  the  eyelids  by  an  incision, 
carried  outwards  from  the  external  angle  towards  the  temple,  and 
then,  raising  the  upper  lid,  to  expose  the  tumour,  divide  the  con- 
junctiva very  cautiously,  lay  hold  of  the  cyst  with  a  pair  of  forceps, 
and  extirpate  as  much  of  it  as  possible. 

Beer's  treatment  of  this  disease  consisted  in  laying  bare  the 
tumour  by  dividing  the  conjunctiva,  and  then  passing  a  thick  silk 
thread  through  the  cyst,  and  through  the  upper  eyelid,  by  means  of  a, 
curved  needle,  knotting  together  the  ends  of  this  seton,  and  drawing 
it  backwards  and  forwards  till  such  a  degree  of  inflammation  should 
be  excited  as  was  likely  to  obliterate  the  cavity  of  the  cyst.  If  after 
24  hours,  this  seemed  insufficient  to  cause  the  necessary  degree  of 
inflammation,  he  moistened  that  part  of  the  seton  which  issued 
from  the  eyelid  with  a  solution  of  lunar  caustic,  or  even  of  pure  pot- 
ash. Still,  if  no  sufficient  adhesive  inflammation  followed,  nor  any 
suppuration  sufficient  to  destroy  the  cyst,  or  even  to  destroy  the 
excretory  duct  supposed  to  be  in  fault,  he  contented  himself  with 
having  in  this  way  obtained  a  palliative  cure.  He  still  retained  the 
seton  for  a  time,  till  the  internal  and  external  openings  became 
callous,  in  the  hope,  that  after  the  thread  was  withdrawn,  the 
patient  might  be  able  to  empty  the  cyst  by  gentle  pressure,  when- 
ever it  should  become  filled.  He  mentions,  that  if  the  evacuation 
takes  place  through  the  external  opening,   the  collected  fluid  is 


94 

squirted  out  in  a  scarcely  visible  stream,  through  the  minute  fistulous 
opening,  to  the  distance  of  several  feet,  till  the  tumour  be  emptied. 
It  strikes  me,  that  rather  than  form  in  this  way  a  troublesome 
fistulous  opening  through  the  upper  eyelid,  the  simple  palliative 
cure  should  be  had  recourse  to,  of  puncturing  the  tumour  through 
the  conjunctiva ;  but  that  it  would  be  preferable,  to  endeavour 
radically  to  remove  the  disease,  by  extirpating  the  cyst  in  the 
manner  already  mentioned. 


SECTION  VIII. TRUE  LACHRYMAL  FISTULA. 

This  disease  consists  in  a  callous  opening,  so  small  as  scarcely 
to  be  visible  to  the  naked  e5^e,  situated  in  the  upper  eyelid,  towards 
its  temporal  extremity,  and  from  which  there  trickles  from  time  to 
time,  a  quantity  of  tears.  If  we  pass  an  Anelian  probe  into  this 
minute  fistula,  we  find  that  the  probe  is  led  directly  towards  the 
lachrymal  gland,  but  we  neither  perceive  any  hardness  of  the  gland, 
feel  any  portion  of  bone  laid  bare,  nor  give  the  patient  any  pain. 

True  lachrymal  fistula  may  arise  from  a  wound  of  the  gland,  or 
of  its  ducts.  More  frequently  it  is  the  eflfect  of  a  neglected  or  mis' 
treated  abscess  of  the  upper  eyelid,  or  of  inflammation  which  had 
passed  into  suppuration,  of  the  cellular  substance  surrounding  the 
lachrymal  gland.  It  may  also  be  the  result  of  an  otherwise  fruit- 
less attempt  to  cure  a  lachrymal  cyst,  by  means  of  the  seton,  as  has 
been  described  in  the  last  section. 

This  almost  capillary  fistula  will  require  the  finest  Anelian  syr- 
inge, to  inject  any  fluid  into  it.  It  has  been  advised  to  widen  the 
fistula,  by  repeated  introductions  of  the  Anelian  probe,  followed  by 
the  use  of  a  piece  of  catgut ;  and  after  this  is  accomplished,  to  in- 
troduce into  the  fistula  a  small  bougie  armed  with  lunar  caustic. 
By  passing  this  bougie  backwards  and  forwards  several  times  with 
a  rotatory  motion,  through  the  fistula,  we  may  expect  to  excite  such 
a  degree  of  inflammation  as  shall  end  in  its  closure. 

Beer  relates  the  case  of  a  stout  country  lad,  who  had  a  fistula  of 
this  kind,  3^  lines  deep,  and  completely  callous.  He  quickly 
passed  into  the  opening,  and  to  the  bottom  of  the  fistula,  a  red 
hot  knitting  needle,  turning  it  round  several  times  upon  its  axis. 
Five  days  afterwards,  the  fistula  was  completely  closed. 


1 


SECTION    IX. MORBID    TEARS. 


The  tears  are  at  all  times  an  irritating  secretion.  The  con^ 
junctiva  is  instantly  reddened  when  they  flow,  and  if  they  are  sc 
profuse  as  to  run  over  on  the  cheek,  the  skin,  with  v/hich  thej 
come  into  frequent  contact,  becomes  inflamed  and  excoriated.  Ii 
soiTie  cases,  the  extraordinary  degree  of  inflammation  which  thi, 
tears  have  excited,  has  led  to  the  supposition,  that  their  chemica^ 
properties  were  changed  by  disease,  so  that  they  had  acquired  ai 


95 

unusual  degree  of  acrid ness.  In  a  supposed  case  of  this  kind, 
which  some  years  ago  attracted  a  considerable  share  of  attention  in 
this  town,  it  was  discovered,  that  the  deep  lines  of  excoriation 
which  ran  down  the  cheeks  of  the  patient,  who  was  a  child,  were 
not  the  work  of  the  tears,  but  the  effects  of  a  deliberate  applica- 
tion of  sulphuric  acid.  The  author  of  this  extraordinary  piece  of 
cruelty,  was  the  woman  who  kept  the  child. 


SECTION    X. LACHRYMAL  CALCULUS. 

The  tears,  like  the  saliva,  occasionally  become  the  source  of 
calcareous  depositions. 

Lachrymal  calculus  does  not  appear  to  have  been  met  with  ob- 
structing the  lachrymal  ducts  ;  but  Professor  Walther  has  recorded 
a  case,  in  which  a  copious  deposition  of  calcareous  matter,  from 
the  tears,  was  continued  for  a  period  of  nearly  ten  weeks,  the 
concretions  being  formed  in  the  folds  of  the  conjunctiva. 

The  patient  was  a  healthy  young  woman,  to  whom  it  happened, 
in  1811,  that  a  small  bit  of  lime  fell  from  the  ceiling  of  a  room 
into  the  left  eye.  Walther  removed  it,  and  the  eye  appeared  to 
have  sustained  no  injury.  In  February,  1813,  she  was  first  at- 
tacked with  severe  toothach,  both  in  the  upper  and  lower  jaw. 
Several  decayed  molares,  in  which  the  pain  was  particularly  vio- 
lent, were  extracted,  but  with  merely  temporary  relief.  Soon 
after  this,  she  had  an  attack  of  rather  obstinate  constipation,  with 
other  symptoms  of  colic ;  but  by  clysters,  fomentations,  (fee.  it  was 
removed.  Towards  the  end  of  July,  of  the  same  year,  she  be- 
gan to  complain  of  a  burning,  stinging  sensation  in  the  left  eye, 
most  severe  when  the  eye  or  eyelids  were  moved,  or  when  she 
was  exposed  to  bright  sunshine.  On  closely  examining  the  organ, 
a  white  angular  concretion  was  discovered  between  the  eyeball  and 
the  lower  eyelid,  towards  the  external  angle  of  the  eye.  It  was 
about  the  size  of  a  pea,  and,  when  removed  from  the  eye,  was 
readily  rubbed  down  between  the  fingers  into  a  greasy  sandy  pow- 
der. Although  the  patient  firmly  denied  that  any  foreign  body 
had  fallen  into  her  eye,  Walther  at  first  supposed,  that  the  sub- 
stance removed  was  a  piece  of  lime  which  had  just  got  into  it. 
He  was  not  a  little  surprised,  however,  when  the  patient  returned 
to  him,  three  days  afterwards,  with  a  calculus  exactly  like  the  first, 
lying  in  the  very  same  place.  The  eye  was  now  considerably  in- 
flamed, the  pain  not  being  confined  to  the  eyeball,  but  extending 
in  the  direction  of  the  supra-orbitary  nerve.  There  was  a  propor- 
tionate sensibility  to  light,  and  increased  flow  of  tears.  The  in- 
flammation of  the  eye  had  commenced  the  preceding  evening, 
accompanied  by  a  violent  paroxysm  of  fever,  vv^ith  shivering,  suc- 
ceeded by  heat.  Although  the  newly  formed  calculus  was  imme- 
diately and  easily  removed,  still,  on  the  following  nmorning,  after  a 
restless  and  distressful  night,  the  violence  of  the  inflammation  was 


96 

much  increased,  and  in  the  lower  fold  of  the  conjunctiva  another 
white  crumbling  concretion  was  perceived,  which,  by  the  succeed- 
ing day,  had  attained  as  large  a  size  as  the  former.  The  upper 
eyehd  was  inflamed,  and  the  margins  of  both  swollen.  The  in- 
flammation was  so  violent  as  to  require  blood-letting,  and  other 
antiphlogistic  remedies.  By  these,  some  alleviation  was  effected, 
but  four  days  afterwards  another  bleeding  was  necessary,  from  an 
increase  of  the  inflami^iatory  symptoms.  In  the  meantime,  the 
formation  of  calculi,  at  the  same  place  in  the  affected  eye,  not 
only  proceeded,  but  larger  concretions  were  produced,  and  with 
greater  rapidity.  The  calcuh  were  now  removed  twice  a  day,  and 
at  length  three  times  a  day  from  the  eye.  Reasoning  from  the 
good  effects  of  potash  in  calculous  affections  of  the  kidney,  Wal- 
ther  prescribed  a  solution  of  a  drachm  and  a  half  of  carbonate  of 
potash  in  four  ounces  of  cinnamon  water,  with  half  an  ounce  of 
syrup.  Of  this  solution,  half  a  tablespoonful  was  taken  four  times 
a  day  ;  and  along  with  this,  the  patient  drank  copiously  of  an  in- 
fusion of  the  herb  jacea. 

After  using  these  remedies  for  six  days,  during  which  time  the 
urine  was  muddy  and  foetid,  and  deposited  a  copious  sediment,  the 
activity  of  the  disposition  to  form  calculi  greatly  diminished.  In 
the  course  of  twenty-four  hours,  there  was  but  one,  and  that  a 
smaller  concretion,  formed,  and  at  length  merely  a  white  crumbling 
powder,  no  longer  consolidated  into  a  mass,  and  which  required  ta 
be  removed  only  every  second  day.  But  while  the  disease  in  the 
left  eye  decreased  and  disappeared,  it  attacked  the  right,  and  at 
the  same  part  of  the  conjunctiva,  between  the  eyeball^  and  lower 
eyelid.  Its  course  here  was  exactly  the  same  as  before  ;  at  first,, 
the  calculi  formed  in  fewer  numbers,  and  more  slow)}',  afterwards 
more  rapidly,  and  in  greater  numbers ;  the  inflammation  of  the 
right  eye  was  at  first  moderate,  and  afterwards  more  severe,  ren- 
dering venesection  twice  necessary.  Nevertheless,  the  disease  never 
attained  the  same  height,  and  was  of  shorter  duration  in  the  right 
eye.  It  gradually  decreased  as  it  had  increased ;  the  concretions 
appearing  at  greater  intervals,  iDecoming  smaller,  and  at  length  en- 
tirely ceasing.  The  whole  course  of  the  disease  occupied  nearly 
ten  weeks.  The  patient's  chest  seemed  to  have  suffered  in  some 
degree,  from  the  repeated  blood-lettings,  altered  manner  of  life,  and 
perhaps  from  the  continued  use  of  alkaline  medicine  ;  she  had  a 
troublesome  cough,  with  considerable  expectoration,  particularly  in 
the  morning,  and  an  altered  appearance.  Walther,  therefore,  or- 
dered her  an  infusion  of  lichen  Islandicus,  and  better  diet.  In 
three  weeks,  she  had  perfectly  recovered.  Some  years  after  this, 
however,  she  was  again  attacked  with  the  same  disease.  Concre- 
tions of  the  former  colour,  size,  and  other  properties,  formed  in  the 
left  eye ;  at  first,  they  lay  between  the  eyeball  and  under  eyelid, 
and  afterwards  between  the  eyeball  and  upper  eyelid.  In  the 
course  of  a  few  days,  the  formation  of  calculi  began  in  the  right 
eye.     On  this  occasion,  both  eyes  were  less  severely  inflamed,  and 


97 

the  disease  was  likewise  of  shorter  duration.  Walther  immediately 
ordered  her  the  solution  of  potash.  The  number  of  calculi  which 
were  daily  generated  soon  diminished,  and  the  whole  jarocess 
ceased  in  shorter  time.  These  concretions  Walther  proposes  to  call 
dacryolites.  On  analysis,  they  were  found  to  be  composed  of  car- 
bonate of  lime,  which  formed  the  greatest  part  of  their  weight ; 
traces  of  phosphate  of  lime  ;  and  coagulable  lymph  or  albumen.* 


CHAPTER  III. 

DISEASES    OF  THE  EYEBROW  AND  EYELIDS. 


J        SECTION  I. INJURIES  OF  THE  EYEBROW  AND    EYELIDS. 

Contusions,  wounds,  and  burns  of  the  eyebrow  and  eyelids, 
even  when  they  may  have  at  first  appeared  trifling,  are  often  pro- 
ductive of  very  serious  consequences.  I  have  already  had  occasion 
to  mention  inflammation  of  the  periosteum,  and  of  the  bones,  as  an 
effect  which  is  sometimes  unexpectedly  produced  by  blows  over  the 
edge  of  the  orbit.  Lagophthalmos  and  eversion  are  apt  to  be  the 
disagreeable  consequences  of  neglected  burns  and  abscesses  of  the 
eyelids  ;  while  incised  and  lacerated  w^ounds  of  the  eyebrow,  and 
of  the  neighbouring  integuments,  even  of  very  small  extent,  are  oc- 
casionally followed  by  complete,  and  but  too  often  incurable,  de- 
privation of  sight. 

1.   Contusion  and  Ecchyvnosis. 

Even  slight  blows  over  the  edge  of  the  orbit  are  apt  to  be  follow- 
ed by  extravasation  of  blood  into  the  loose  cellular  membrane  of  the 
eyelids.  The  extravasation  or  ecchymosis  does  not  make  its  ap- 
pearance immediately  after  the  blow.  Five  or  six  hours  generally 
elapse  before  the  sv^^ollen  eyelid  assumes  the  livid  colour  denoting 
the  rupture  of  blood  vessels  and  the  subcutaneous  effusion  of  blood. 
In  some  instances,  however,  the  ecchymosis  is  sudden ;  and  the 
quantity  of  blood  being  considerable,  a  degree  of  fluctuation  is  felt  in 
the  swollen  lid.  It  very  rarely  happens  that  the  blood  effused  into 
the  eyelids  operates  as  a  foreign  substance,  or  excites  inflammation. 
It  is  generally  absorbed  in  the  course  of  from  fourteen  to  twenty 
days,  the  swelhng  subsiding,  and  the  skin  gradually  losing  its  livid 
colour  as  the  absorption  goes  on,  becoming  first  brownish,  and  then 
yellow. 

*  Graefe  und  Walther's  Journal  der  Chirurgie  und  Augen-Heilkunde.  Vol.  i.  p. 
163.     Berlin,  1820. 

13 


98 

The  indications  in  cases  of  bruises  and  ecchymosis  of  the  eyelids 
are  to  abate  the  inflammation,  which  is  apt  to  attend  this  sort  of 
accident,  and  to  promote  the  absorption  of  the  effused  blood. 

The  first  of  these  objects  is  to  he  obtained  by  the  appHcation  of 
leeches,  followed  by  the  continued  use  of  evaporating  and  slightly 
astringent  lotions.  More  powerful  astringents,  and  gentle  pressure 
are  employed  to  accomplish  the  second. 

To  remove  a  black  eye,  as  it  is  termed,  quickly,  is  the  great  desid- 
eratum with  the  patient,  who  often  visits  us  late  in  the  evening,  with 
a  woful  dread  of  what  his  appearance  must  be  next  morning,  un- 
less we  have  some  a])plication  which  can  prevent  or  remove  the 
discoloration.  If  the  blow  has  been  severe,  there  can  be  no  ques- 
tion that  leeching  is  the  proper  mode  of  treatment.  "When  the  pa- 
tient is  a  strumous  child,  the  application  of  leeches  is  imperatively 
called  for,  not  indeed  so  much  for  the  removal  of  the  ecchymosis,  as 
for  preventing  inflammation  of  the  periosteum  and  bones. 

If  the  blow  has  been  slight,  and  the  patient  is  a  robust  adult, 
compresses  wet  with  a  solution  of  acetas  plumbi,  or  murias  ammo- 
niee,  may  be  appUed,  and  kept  in  close  contact  with  the  skin,  by 
means  of  a  roller  going  round  the  head.  A  popular  remedy  is  a 
cataplasm  of  the  bruised  roots  of  the  convallaria  multiflora  or  Solo- 
mon's seal.  The  roots  are  beat  into  a  pultaceous  mass  in  a  mortar, 
and  are  reapplied  every  half  hour  for  three  or  four  hours,  or  longer, 
if  necessary.  They  cause  a  degree  of  redness  and  oedematous 
swelling,  and  have  been  supposed  to  act  by  means  of  the  oedema 
which  they  excite,  diluting  the  effused  blood,  and  thus  promoting 
its  absorption.  If  long  continued,  they  produce  too  much  inflam- 
mation ;  and  if  the  skin  be  abraded,  they  are  too  irritating  to  be 
applied  at  all. 

Whatever  application  we  make  choice  of,  whether  an  astringent 
solution,  or  the  convallaria  roots,  the  patient  ought  to  be  directed 
to  keep  the  eyelids  at  rest,  and  to  maintain  a  certain  degree  of  pres- 
sure on  them  by  means  of  wet  folds  of  linen,  or  the  cataplasm. 
Motion  of  the  lids  appears  to  throw  the  effused  blood  more  into 
their  loose  cellular  substance,  while  rest  and  gentle  pressure  tend 
both  to  prevent  this,  and  to  promote  absoi*ption. 

Those  who  are  obliged  to  appear  in  public,  sometimes  contrive 
to  paint  the  discoloured  skin  from  day  to  day,  till  the  natural  colour 
is  restored. 

2.  Burns  and  scalds 

Of  the  eyelids  require  to  be  treated  with  particular  care,  for  in 
neglected  cases,  there  is,  on  the  one  hand,  the  danger  of  anchylo- 
blepharon,  or  union  of  the  edges  of  the  lids,  and  on  the  other,  of 
ectropium  and  lagophthalmos. 

It  is  chiefly  in  cases  of  scalds  from  boiling  water,  and  other  hot 
or  caustic  fluids,  as  sulphuric  acid,  in  which  the  cuticle  covering  the 
edges  of  the  lids,  has  been  detached,  and  the  patient  afterwards 


99 

allowed,  from  carelessness,  to  lie  for  a  length  of  time  with  the  lids 
shut,  that  anchylo-blepharon  follows.  It  may  always  be  prevented, 
by  obliging  the  patient  to  open  his  e3'es  frequently,  and  introducing, 
along  their  edges,  a  little  unguentum  oxidi  zinci,  or  other  mild 
salve,  melted  on  the  point  of  the  finger.  Sym-blepharon,  or  union 
of  the  lids  to  the  eyeball,  is  sometimes  produced,  when  the  conjunc- 
tiva has  been  injured  by  the  burn  or  scald,  and  is  to  be  obviated  in 
a  similar  way. 

Burns  and  scalds  of  the  external  surface  of  the  lids,  which  have 
not  been  sufficiently  severe  to  produce  a  separation  of  the  cuticle, 
much  less  to  destroy  the  texture  of  the  cutis,  require  merely  to  be 
kept  constantly  wet,  for  24  hours,  by  means  of  a  fold  of  linen  dip- 
ped in  a  mixture  of  vinegar  and  tepid  water.  The  same  applica- 
tion is  also,  I  conceive,  the  best,  in  cases  in  which  the  skin  is  blis- 
tered, only,  that  as  soon  as  the  blister  has  fairly  formed,  it  ought  to 
be  punctured  with  a  needle,  to  let  its  contents  escape.  After  the 
first  24  hours,  a  piece  of  soft  linen,  spread  with  the  ceratum  simplex 
is  to  be  applied. 

Burns  so  severe  as  to  destroy  the  texture  of  the  cutis,  heal  only 
by  a  slow  process  of  granulation  and  cicatrization.  The  granula- 
tions upon  which  the  new  skin  is  formed,  are  afterwards  absorbed, 
30  that  a  great  degree  of  contraction  is  produced  ;  and  if  the  eyelids 
are  involved  in  the  cicatrice,  they  are  shortened  or  everted.  This 
happens  more  frequently  to  the  lower,  but  occasionally  to  the  upper 
lid,  while  in  some  cases  of  destruction  of  the  skin  stretching  from 
the  outer  angle  of  the  eye  towards  the  temple,  we  find  after  the 
burn  has  healed,  that  both  lids  are  dragged  outwards,  and  their  in 
ternal  surface  exposed.  The  worst  case  of  eversion  of  the  lids,  from 
a  burn,  which  I  have  seen,  was  consequent  to  total  destruction  of 
a  large  portion  of  the  skin  of  the  temple  and  face,  occasioned  by  a 
child  falling  against  the  fire.  The  lolie  of  the  ear  was  lost,  the  cica- 
trice was  very  extensive,  and  both  lids  were  everted.  In  such  a 
case,  it  is  impossible  to  prevent  altogether  the  displacement  of  the 
lids,  attendant  on  tiie  contraction  of  the  cicatrice  ;  but,  in  ordinary 
cases,  much  may  be  done  by  careful  dressing  and  bandaging. 
The  lids  must  be  kept,  as  much  as  possible,  on  the  stretch,  during 
the  progress  of  cicatrization  ;  for  if  this  is  not  done,  little  or  no  new 
skin  will  be  formed,  but  the  ulcer  will  be  covered  at  the  expense  of 
the  loose  integuments  around,  in  the  same  way  as  an  ulcer  of  the 
scrotum  will  sometimes  heal  up  without  almost  any  formation  of 
new  skin  at  all.  The  patient  then,  in  whom  the  cicatrization  of  a 
burn  in  the  neighbourhood  of  the  eyelids  is  going  on,  ought  not  to 
be  allowed  to  use  his  eyea,  but  ought  to  keep  the  lids  constantly 
shut,  except  when  the  dressings  are  changed  ;  pledgets,  spread  with 
the  ceratum  simplex,  ought  to  be  laid  upon  the  hds,  and  round  the 
head  a  roller  ought  to  be  applied  so  as  to  press  gently  on  the  lids, 
and  keep  them  on  the  stretch.  This  will  appear,  no  doubt,  a  very 
tedious  and  annoying  mode  of  treatment.     To  be  allow^ed  to  use 


100 

the  eyes,  would  be  much  more  agreeable  to  the  patient,  till  he  found, 
as  soon  as  the  process  of  healing  was  finished,  that  he  had  lost  the 
power  of  closing  the  lids,  or  that  a  portion  of  their  inner  surface  was 
permanently  exposed  by  eversion. 

Burns  by  gunpowder  are  to  be  treated  in  the  same  way  as  other 
burns,  except  when  the  grains  of  powder  have  been  forced  into  the 
skin  of  the  eyelids.  When  this  is  the  case,  the  grains  are  to  be 
carefully  picked  out.  one  by  one,  with  the  point  of  a  needle,  an  ope- 
ration which  sometimes  requires  several  houi-s  to  accomplish.  We 
should  not  trust  much  to  the  application  of  a  poultice  under  such 
circumstances,  which  is  recommended  with  the  view  of  dissolvhig 
and  bringing  away  the  grains  of  the  powder.  If  the  skin  is  ailow- 
ed  to  heal  over  them,  they  will  remain  indelible. 

3.  Incised  and  Lacerated    Wounds. 

Punctured  wounds  of  the  eyebrow  and  eyelids,  are  in  general, 
not  attended  by  any  particular  had  consequences.  We  must  l)e  on 
our  guard,  of  course,  lest  a  punctured  wound  of  the  upper  lid  has 
gone  deeper  than  its  Vnere  external  appearance  might  denote,  and 
the  instrument  with  which  the  wound  was  inflicted  perhaps  pene- 
trated deep  into  the  orbit,  or  through  the  orbitary  plate  of  the  fron- 
tal bone. 

The  edges  of  incised  wounds  of  the  eyebrow  are  to  be  brought 
accurately  together,  and  retained  by  shps  of  adhesive  plaster  ;  or  if 
these  seem  insuliicient,  the  interrupted  suture  is  to  be  employed, 
with  slips  of  court-plaster  between  the  stitches.  The  same  practice 
is  to  be  followed  in  incised  wounds  of  the  eyelids.  Even  when  they 
are  parallel  to  the  fibres  of  the  orbicularis  palpebrarum,  and  impli- 
cate only  the  integuments,  we  shall  find  the  interrupted  suture  the 
best  means  of  maintaining  the  edges  of  the  wound  in  exact  apposi- 
tion, and  thereby  preventing  any  unsightly  cicatrice.  Still  more 
necessary  are  stitches,  where  the  whole  thickness  of  the  hd  has 
been  divided,  either  traversel}'  or  perpendicularly.  When  the  wound 
is  transverse,  we  may  content  ourselves  with  including  the  integu- 
ments only  in  the  suture  ;  but  in  perpendicular  wounds,  the  needle 
ought  to  pass  through  the  whole  thickness  of  the  divided  hd.  After 
the  stitches  are  inserted,  and  the  shps  of  plaster  applied,  the  eyelids 
are  to  be  closed,  and  covered  with  a  pledget  spread  with  simple  ce- 
rate. A  folded  piece  of  hnen  is  to  be  laid  also  over  the  sound  e3^e, 
and  a  roller,  going  round  the  head,  is  to  press  gently  upon  both 
eyes,  so  as  at  once  to  keep  the  dressings  in  their  place,  and  to  re- 
strain the  lids  from  moving.  Generally,  by  the  third  day,  union 
is  effected,  so  that  the  threads  may  be  cut  out.  the  slips  of  plaster 
being  then  replaced,  as  well  as  the  compresses  and  roller. 

A  perpendicular  wound  of  the  upper  eyehd,  passing  through  its 
whole  thickness,  so  as  to  divide  it  into  two  flaps,  somewhat  hke  the 
two  portions  of  a  hare-lip,  has  received  the  name  of  coloboma.  If 
neglected,  the  edges  of  such  a  wound  are  apt  to  cicatrize  separately. 


101 

A  pitnilar  deformity  is  said  to  occur  con^enitally.  An  operation^ 
analogous  to  that  for  the  cure  of  hare-lip,  is  to  be  had  recourse  to 
under  such  circumstances.  The  edges  of  the  coloboma  are  to  be 
pared,  and  then  accurately  brought  and  kept  in  contact,  by  one  or 
two  stitches  and  slips  of  court  plaster,  till  reimion  is  completed. 

It  occasionally  happens,  that  through  a  wound  of  either  eyelid, 

the  eyeball  is  also  wounded.     This  does  not  alter  the  mode  of  pro- 

[  ceeding  with  regard  to  the  lid  ;  nor  need  we  be  very  apprehensivcj 

that  in  consequence  of  such  an  injury,  union  shall  take  place  be- 

:  tween  the  eyelid  and  eyeball.     Such  an   injury  will  generally  be 

inflicted  by  the  point  of  some  sharp  instrument  suddenly  directed 

against  the  eye,  while  the  lids  are  open ;  but  as  soon  as  the  lids 

close,  the  wounded  eyeball  will  roll  upwards,  so  that  the  wound  of 

the  lid  and  that  of  ihe  ball  will  no  longer  correspond. 

j      Lacerated  wounds  of  the  eyebrow  and  eyelids  do  not  so  readily 

admit  of  union  as  incised  wounds.     The  swelling,  inflammation, 

i  and  suppuration,  which  are  apt  to  ensue,  often  prevent  immediate 

union.     Still,  we  ought  to  treat  lacerated  wounds  of  these  parts 

i  almost  exactly  as  we  should  do  incised  wounds.     Having  carefully 

'.  cleansed  the  wound,  and  removed  any  foreign  substances  which  may 

,  have  been  forced  into  the  cellular  membrane,  we  bring  the  edges 

j  accurately  together.     If  the  means  of  reunion  succeed,  we  have 

;  gained  our  object.     If  they  fail,  or  if  they  seem  to  produce  addi- 

itional  irritation,  they  must  be  removed,  and  the  cure  must  be  ef- 

1  fected  by  the  second  intention.     When  the  contusion  and  laceration 

[  attending  a  v/ounded  eyehd,  are  very  great,  of  course  no  attempt  at 

I  union  need  be  made,  till  by  leeching,  and  poulticing  with  bread 

i  and  water,  the  irritation  and  tumefaction  shall  have  subsided.     By 

;  guarding  against  motion,  and  by  the  careful  use  of  compresses  and 

;  adhesive  plasters,  after  the  parts  have  become  quiet,  we  shall  often 

be  able  to  accomplish  reunion,  without  any  considerable  deformit}^, 

or  displacement  of  the  injured  parts. 

,      Wounds  of  the  upper  eyelid  are  occasionally  followed  by  palsy, 
I  in  consequence  of  the  injury  done  to  the  levator  palpebrae,  or  to  the 
'nervous  branch  with  which  it  is  supplied  by  the  third  pair  or  motor 
i  ocuh.     This  branch,  however,  cannot  be  reached,  unless  the  wound 
peneti-ates  pretty  deep  into  the  orbit,  and  traverses  the  levator  mus- 
cle.    The  patient,  when  he  wishes  to  see,  is  obhged,  as  Ambrose 
Pare  observes,*  to  raise  the  eyelid  with  his  finger.     Pare  attributes 
;this  consequence  of  a  wound  of  the  upper  eyehd,  to  unskilfulness, 
lor  inadvertence,  on  the  part  of  the  surgeon,  inasmuch  as  he  must 
have  omitted  sewing  the  wound  properly,  and  applying  the  neces- 
sary compresses  and  bandage.     M.  Ribes   mentions   the  case  of  a 
soldier,  who  had  received  a  cut  from  a  sabre  in  the  upper  eyelid, 
towards  the  superior  edge  of  the  tarsus.     The  wound  liealed  readily ; 
but  the  patient,  even  while  he  retained  the  faculty  of  vision,  saw 

*  CEuvres.  Liv.  x.  Chap.  24. 


102 

none,  on  accouot  of  the  impossibility  of  raising  the  upper  eyelid, 
which  continued  constantly  depressed.*  Such  facts,  while  iliey 
must  injpress  us  with  the  importance  of  leaving  nothing  undone 
which  is  likely  to  procure  a  complete  reunion  of  the  divided  parts, 
may  serve  also  to  warn  against  pronouncing  a  prognosis  too 
decidedly  favourable,  in  those  cases  in  which  we  have  reason  to 
suspect  that  the  levator  of  the  upper  eyelid,  or  its  nerve,  has  been 
materially  injured. 

Even  slight  wounds  of  the  eyebrow  and  eyelids  have  sometimes 
been  followed  by  very  important  effects.  1  have  already  referredt 
to  the  cases  recorded  by  Dease  and  Petit,  in  which  injuries  of  this 
sort  were  followed  by  inflammation  within  the  cranium,  and  death. 
The  loss  of  vision  is  another  consequence  arising  from  apparently 
trifling  injuries  of  the  eyebrows  and  eyelids,  which  has  attracted 
attention  from  the  time  of  Hippocrates.  Thus,  Camerarius  relates 
the  case  of  a  young  man,  who  had  received  a  slight  wound  at  the 
inner  angle  of  the  left  eye,  close  to  the  upper  eyelid.  The  wound, 
though  small,  penetrated  to  the  bone,  and  the  patient  inmiediately 
felt  a  severe  pain,  which  was  attended  by  sweUing  of  the  part,  and 
by  palsy  of  the  right  side  of  his  body.  The  vision  of  the  right  eye 
became  dim,  and  that  of  the  left,  was  totally  lost,  although  nothing 
appeared  diseased  about  the  eye,  except  a  slight  dilatation  of  the 
pupil.  The  left  upper  eyelid  was  also  paralyzed.  The  use  of  hot 
mineral  waters  seemed  to  restore  the  motion  of  the  lid,  and  also  of 
the  right  leg  and  arm.  The  sight  of  the  right  eye  was  in  some 
degree  recovered,  but  that  of  the  left  was  irremediably  lost.  Mor- 
gagni  was  consulted  by  a  lady,  who  had  been  wounded  close  to  the 
left  eye,  in  two  places,  by  the  fragments  of  the  glass  of  a  carriage 
window.  She  had  seen  none  during  the  four  days  which  followed 
the  accident.  One  of  the  wounds  was  near  the  outer  angle,  and 
the  other,  which  was  smaller,  was  under  the  commencement  of  the 
eyebrow. 

Sabatier  quotes  these  facts  as  illustrative  of  the  effects  of  injuries 
done  to  the  branches  of  the  fifth  pair  of  nerves. +  He  supposes,  and 
the  same  supposition  has  been  adopted  by  Beer  and  others,  that  in 
such  cases  the  injury  of  the  supra-orbitary  nerve,  or  of  some  other 
of  the  branches  of  the  fifth  pair,  operates  sympathetically  on  the 
eye,  through  the  medium  of  the  nasal  branch  o^  that  nerve,  which 
assists  in  the  formation  of  the  lenticular  ganglion.  Admitting  this 
supposition  to  be  true,  the  question  naturally  arises,  how  an  injury 
of  the  fifth  pair,  operating  through  the  medium  of  the  lenticular 
ganglion,  should  produce  blindness.  This  question  has  been  taken 
up  by  M.  Ribes,  who  contends,  that  the  ciliary  or  iridal  nerves,  the 
branches  given  off  by  the  lenticular  ganglion,  do  not  terminate 
altogether  in  the  iris,  but  that  several  of  them,  having  reached  the 

*  Memoires  de  la  Societe  Aledicale  d'Emulation.    Vol.  vii.  p.  92.    Paris,  1811. 
t  See  page  3.  t  Traite  d'Anatomie.  Tome  III.  p.  2-2-3.  Paris,  1791. 


103 

anterior  part  of  the  eye,  pierce  the  choroid,  and  having  penetrated 
into  the  corpus  ciliare,  bend  towards  the  retina.* 

Beer  has  discussed  the  subject  of  amaurosis  from  wounds  of 
the  branches  of  the  fifth  pair,  at  great  length.!  The  substance  of 
his  observations  is,  that,  in  severe  cases,  the  bhndness  may  be  in- 
stantaneous ;  in  less  severe  cases  slow  ;  sometimes  not  till  after  the 
process  of  cicatrization  has  begun,  or  is  completed  ;  that  it  may  be 
a  consequence  of  tension  of  the  nerve,  or  pressure  upon  it,  produced 
by  the  cicatrice  ;  that  the  pupil  is  sometimes  expanded,  sometimes 
contracted,  in  such  cases ;  that  we  must  beware  of  confounding 
amaurosis  from  wounds  of  the  branches  of  the  fifth  pair,  with 
amaurosis  from  concussion  of  the  eyeball,  and  perhaps  laceration 
of  the  retina,  and  bear  in  mind,  that  along  with  a  wound  of  the 
eyebrow  or  eyelids,  there  may  have  been  a  severe  blow  on  the  eye- 
ball ;  that  in  cases  in  which  the  amaurosis  is  really  sympathetic, 
vision  may  often  be  completely  restored  by  dividing  the  lacerated 
nerve.  He  insists  particularly  on  this  last  point,  telhng  us  not  to 
be  afraid  of  paralyzing  the  orbicularis  palpebrarum  by  dividing  the' 
supra-orbitary  nerve. 

Chopart,t   Boyer,§    and  others,  have  adopted  a  different  view 
from  that  of  Sabatier  and  Beer,  upon  the  subject  of  amaurosis  con- 
sequent to  wounds  of  the  eyebrow  and  eyehds.     They  have  ob- 
served that  blindness  is  not  the  only  attendant  on  such  injuries; 
but  that  convulsions,  palsies,  dehrium,  coma,  and  even  death,  have 
lot  unfrequently   been   known  to  result,   apparently    from   such 
wounds,  but,  in  fact,  from  disease  of  the  brain,  either  concomitant 
i«^ith,  or  produced  by,  the  external  injury.     They  have,  therefore, 
concluded,  that  we  ought  not  to  account  the  amaurosis  a  mere 
liervous,  or  sympathetic  effect,  propagated  from  the  injured  nerve 
:)f  the  foce  to  the  nerves  of  the  iris  or  retina ;  but  that  the  irritation 
uising  from  the  wound  is  propagated  to  the  brain,  that  the  nervous 
lymptoms  which  follow,  are  to  be  ascribed  to  disease  arising  in  that 
)rgan  ;  and  that  the  affection  of  the  brain,  or  of  its  membranes,  in 
liuch  cases,  generally    partakes   of   the  nature  of  inflammation, 
bllowed  by  effusion  or  by  suppuration.     In  many  cases  of  this  sort, 
he  result  has  been  fatal,  and  dissection  has  demonstrated  the  truth 
;>f  these  views ;  while  in  cases  that  have  recovered,  we  should  be 
I ed  to  suspect,  that  the  amaurosis,  and  other  nervous  symptoms, 
jiave  disappeared,  not  in  consequence  of  dividing  the  injured  nerve, 
)Ut  in  consequence  of  the  diseased  state  of  the  brain  having  sub- 
ided. 

The  instances  on  record  which  show  that  very  serious,  or  even 
ital,  disease  of  the  brain  may  arise  in  connexion  with  apparently 

*  Memoires  dela  Societc  Medicale  d' Emulation,  Tome.  vii.  p.  99.     Paris,  1811. 
t  Lehre  von  den  Angenkrakheiten.     Vol.  i.  pp.  176,  185,  189.     Wien.  1833. 
t  Treatise  on  Chirurgical  Diseases,  translated  by  Turnbull.     Vol.  L  p.  267.    Lon- 
on,  1797. 
§  Traite  des  Maladies  Chirurgicales.     Tome  v.  pp.  245,  248.    Paris,  1816. 


104 

slight  wounds  of  the  eyebrow  or  eyelids,  are  sufficiently  numerousv 
Morgagni  has  narrated  several  highly  interesting  cases  of  this  sort 
in  his  51st  epistle.  The  conclusion  to  be  drawn  from  such  cases 
is  evidently  this,  that  we  must  watch  the  effects 'of  such  injuries, 
keep  the  patient  quiet,  and  on  low  diet,  and  have  recourse  freely 
to  the  use  of  blood-letting,  if  there  appear  the  slightest  symptoina 
of  any  affection  of  the  brain,  or  its  membranes,  as  convulsions, 
sopor,  bUndness,  or  the  like.  Similar  practice  must  be  followed  if 
we  have  reason  to  conclude  that  the  amaurosis,  concomitant  with 
a  wound  of  the  eyebrow  or  eyelids,  is  the  result  not  of  the  injury 
done  to  the  branches  of  the  fifth  pair,  but  of  concussion  of  the  eye- 
ball. I  have  seen  numerous  examples  of  a  blow  on  the  eye  in- 
ducing amaurosis,  without  in  the  least  affecting  the  vascularity, 
or  the  transparency,  of  its  different  textures ;  and  I  can  easily  con- 
ceive, that  had  any  wound  of  the  integuments  in  the  neighbor- 
hood of  the  eye  accompanied  such  blows,  I  might  have  been  led 
into  the  erroneous  supposition,  that  the  amaurosis  was  not  direct, 
but  sympathetic. 

Jt  is  proper  also,  to  mention,  before  quitting  this  subject,  that 
the  section  of  the  injured  nerve,  proposed  by  Beer,,  and  which  he 
expressly  states  to  be  a  means  which  had  never  failed  him,  has 
been  repeated  in  several  instances  by  others,  without  producing 
any  effect  upon  the  amaurosis.  "  I  have  met,"  says  Dr.  Hennen. 
"  with  one  or  two  cases  of  amaurosis  from  wounds  of  the  supra- 
orbitary  nerve  ;  the  perfect  division  of  the  nerve  produced  no  alle- 
viation of  the  complaint,  but  after  some  time,  the  eye  partially 
recovered."*  "  When  the  defective  vision  follows  a  wound  on  tb€ 
forehead,"  says  Mr.  Guthrie,  "  the  only  hope  of  relief  that  we  are 
at  present  acquainted  with,  lies  in  a  free  incision  made  down  tc 
the  bone  in  the  direction  of  the  original  wound  ;  and  even  of  tlu 
efficacy  of  this,  1  am  sorry  I  cannot  offer  testimony  from  my  owi 
practice,  having  failed  in  every  case  in  which  I  tried  it."t 

It  is  well  known  that  every  w^ound  of  the  branches  of  the  fiftl 
pair  does  not  produce  amaurosis.  Magendie  has  even  endeavourec 
to  show  by  experiment  that  pricking  these  branches,  especially  tb« 
supra-orbitary,  infra-orbitary,  and  lachrymal,  has  no  bad  effec 
on  vision.  He  has  been  led  to  propose  galvanising  the  eye,  b; 
touching  these  nerves  directly  with  the  Avires  communicating  witi 
the  opposite  poles  of  a  galvanic  trough. +  The  consideration  c 
these  facts  naturally  leads  us  to  regard  with  still  greater  doubt,  th 
alleged  occurrence  of  purel}^  sympathetic  amaurosis  from  sligb 
injuries  of  the  fifth  pair,  and  to  suspect  that  in  all  the  suppose^ 
cases  of  this  sort  there  has  been  either  concussion  of  the  eyeball,  c 
disease  excited  within  the  cranium. 

*  Observations  on  Some  Important  Points  in  Military  Surgery,  p.  366.  Edin.  181i 
t  Lectures  on  the  Operative  Surgery  of  the  Eye,  p.  102.     London,  1823. 
t  Journal  de  Physiologic.     Tome  vi  156.     Paris,  1826.. 


i 


105 


SECTION    II. PHLEGMONOUS  INFLAMMATION  OF  THE  EYELIDS. 

Phlegmonous  inflammation  of  the  eyeUds  occurs  more  frequent- 
ly in  children  than  in  adults,  and  oftener  in  the  upper  than  in  the 
lower  lid. 

Symptoms.  The  affected  lid  is  of  a  deep-red  colour,  very 
painful  on  being  touched,  hot,  and  swollen.  The  swelling  spreads 
from  the  edge  of  the  lid,  but  is  generally  limited  in  its  progress 
[by  the  edge  of  the  orbit.  It  is  soon  so  considerable  as  to  prevent 
!ihe  eye  from  being  opened  ;  the  pain  is  much  increased  by  the 
east  attempt  to  move  the  eye.  If  the  inflammation  is  unchecked, 
;he  pain  becomes  pulsative,  the  sweUing  increases,  assumes  a  livid 
red  colour,  and  begins  to  point,  generally  about  the  middle  of  the 
lid.  The  pain  is  now  attended  by  a  pricking  sensation.  The 
lardness  of  the  swelUng  diminishes,  and  at  its  most  prominent 
Dart  it  becomes  less  sensitive  to  the  touch.  The  lid  has  suppura- 
ed,  and  the  fluctuation  of  the  matter  is  now  distinct. 

Causes.  Abrasion,  and  other  injuries  of  the  skin  covering  the 
iyelids,  appear  to  bring  on  phlegmonous  inflammation ;  but  not 
,  infrequently  the  cause  is  obscure,  especially  when  children  are  the 
subjects. 

Prognosis.  This  disease  being  neglected  or  mistreated,  a  por- 
ion  of  the  integuments  of  the  eyelids  may  be  lost,  from  ulceration, 
Dr  from  the  inflammation  going  on  to  gangrene;  the  consequence 
ivill  be  contraction  of  the  lid,  and  ectropium. 

Treatment.  Leeches  to  the  swollen  lid,  followed  by  the  con- 
stant application  of  an  evaporating  lotion,  constitute  the  local  treat- 
ment during  the  first  or  purely  inflammatory  stage.  The  patient 
s  also  to  be  purged,  to  keep  at  rest,  and  live  low.  If  these  means 
ire  found  insufficient  to  procure  the  resolution  of  the  inflammation, 
1  warm  bread  and  water  poultice  is  to  be  applied,  and  as  soon  as 
fluctuation  is  distinct,  the  abscess  is  to  be  opened  with  the  lancet, 
'.he  incision  being  made  transversely,  or  parallel  to  the  natural 
folds  of  the  skin  of  the  eyelids.  The  matter  is  generally  found 
immediately  under  the  skin.  The  poultice  is  to  be  continued  till 
the  swelling  subside,  and  the  abscess  cease  discharging. 


SECTION    III. ERYSIPELATOUS    INFLAMMATION    OF    THE    EYE- 
LIDS. 

In  erysipelas  of  the  face,  the  eyelids  are  always  much  affected, 
especially  the  upper.  This  disease  may  also  arise  in  the  lids,  and 
be  confined  to  them. 

Local  iSymptom,s.  The  lids  are  much  swollen,  so  that  the  eye 
is  shut  up.  The  sweUing  is  of  a  pale  red  colour,  but  sometimes  of 
a  bright  scarlet,  or  even  of  a  deep  and  livid  red.  The  redness  dis- 
appears on  pressure,  but  instantly  returns  when  the  pressure  is  re- 

14 


106 

moved.  The  pain  is  in  general  not  considerable,  nor  pulsative. 
The  swelling  feels  hot,  and  the  patient  complains  of  a  stinging  and 
burning  sensation  in  the  part.  A  serous  effusion  frequently  takes 
place  on  the  inflamed  surface,  tlie  cuticle  being  elevated  by  vesicles, 
which  bursting,  allow  the  fluid  they  contain  to  escape,  and  forra 
crusts.  These  falling  off,  the  skin  is  generally  left  in  a  sounc 
state,  the  sweUing  has  by  this  time  subsided,  and  the  eyelids  have 
recovered  their  power  of  motion. 

In  more  severe  cases,  the  inflammation  runs  on  into  suppuratioi 
and  sloughing  of  the  subcutaneous  cellular  membrane.  In  sucl 
cases,  the  redness  has  more  of  the  livid  hue,  the  swelhng  is  mon 
considerable,  and  soon  becomes  tense  and  firm,  the  sensation  o 
heat  and  pain  is  much  aggravated,  and  is  attended  by  throbbing 
At  first  the  cellular  texture  contains  a  v/hey-like  serum.  Mr.  Law 
rence  mentions  his  having  seen  this  effusion  into  the  eyelids  almos 
of  milky  whiteness.  It  gradually  becomes  yellow  and  purulent,  i 
is  diffused  through  the  swollen  cellular  membrane,  which  become 
so  disorganized  that  it  comes  away,  after  the  abscess  is  opened  o 
gives  way,  in  shreds  soaked  with  matter.  This  erysipelatous  ab 
scess  differs  from  a  phlegmonous  abscess  in  this  respect,  that  it  i 
not  bounded  by  a  sphere  of  adhesive  inflammation,  but  extend 
extremely  irregularly  in  different  directions,  producing  extensiv 
sloughings  of  the  cellular  membrane.  An  abscess  of  this  sort  com 
municates  a  peculiar  boggy  impression  to  the  finger.  If  neglectec 
suppuration  may  take  place  as  well  below  as  exterior  to  tlie  orbic 
ularis  palpebrarum,  and  even  destroy  the  ligamentous  layer  of  th 
eyelids.  At  length,  the  integuments  give  way  in  one  or  mor 
points,  a  small  quantity  of  matter  is  discharged,  and  shreds  of  dee 
troyed  cellular  membrane  may  be  extracted.  Left,  in  this  way,  t 
run  its  course,  severe  erysipelas  leaves  the  lids  so  altered,  and  thei 
several  textures  so  agglutinated  from  the  loss  of  the  connecting  ce. 
lular  membrane,  that  they  are  long  before  they  recover,  if  ever  the  . 
recover,  their  natural  pliancy  and  mobility. 

The  conjunctiva.  Meibomian  follicles,  and  excreting  lachrynic 
organs,  always  suffer  more  or  less  in  erysipelas  of  the  eyelids,  j. 
mucous  secretion  accumulates,  during  the  night,  along  the  edges  ( 
the  lids,  and  in  the  nasal  angle  of  the  eye.  The  absorption  of  th 
tears  is  impeded,  and  there  is  a  slight  afcumulation  of  mucus  i 
the  lachrymal  sac.  In  some  cases,  a  stillicidium  lachrymarum  n 
mains  after  all  the  other  s3niaptoms  have  disappeared.  In  sever 
cases,  ending  in  diffuse  suppuration,  the  matter  occasionally  pene 
trates  into  contact  with  the  lachrymal  sac,  which  is  already  di; 
tended  by  the  presence  of  an  inordinate  quantity  of  mucus.  Afte 
the.  integuments  in  such  a  ca^e  give  way,  the  appearance  of  th 
parts  is  apt  to  impose  upon  a  superficial  observer.  He  probabl 
pronounces  the  case  to  be  a  fistula  lachrymalis;  and  forthwith  open 
the  sac.  It  may  happen,  however,  that  the  purulent  matter  of  a 
erysipelatous  abscess  actually  penetrates  into  the  lachrymal  sa< 


107 

which  ihns  comes  to  be  filled  with  pus  received  from  withont,  in 
the  production  of  which  i(s  lining  membrane  has  had  no  share. 
SThe  latter  case,  which,  for  the  sake  of  distinction,  may  be  called 
spurious  fistula  of  the  lachrymtii  sac,  must  be  carefully  distin- 
Iguished  both  from  the  former,  in  which  the  sac  is  entire  though 
distended  with  mucus,  and  from  those  diseases  hereafter  to  be  des- 
icribed,  in  which  the  purulent  matter,  which  fills  the  sac,  is  the  re- 
|3ult  of  inflammation  of  the  lining  membrane  of  the  sac  itself.  The 
!3ac,  and  the  lachrymal  canals,  may  suffer  so  much  by  being  in- 
ivolved  in  the  erysipelatous  abscess,  as  to  be  rendered  unfit  ever  af- 
jterwards  to  execute  their  functions. 

Constitutional  symptoTns.  Erysipelas  of  the  eyelids  is  gene- 
1  rally  preceded  by  rigors,  and  attended  by  considerable  febrile  irrita- 
;.ion.  The  tongue  is  loaded,  and  the  digestive  organs  much  de^ 
ji;anged. 

|l  Causes.  As  this  disease  frequently  arises  suddenly,  without  any 
iocal  injury,  it  probably  owes  its  origin  to  some  peculiar  state  of  the 
ktmosphere,  or  to  contagion.  It  is  certainly  much  more  apt  to  at- 
lack  those  whose  stomach  and  bowels  are  in  bad  order.  Local 
i'auses,  as  slight  blows,  the  stings  of  wasps  and  other  insects,  leech- 
)ites,  exposure  of  the  eyes  suddenly  to  cold  after  much  exposure  to 
neat  or  after  long-continued  weeping,  and  the  like,  frequently  ope- 
;iate  in  its  production. 

Treatment.  An  emeto-cathartic  is  the  best  of  all  general  rem^ 
:die3  in  erysipelas  ;  for  example,  one  or  two  grains  of  tartras  anti- 
nonii,  with  an  ounce  or  two  of  sulphas  magnesiee,  dissolved  in  two 
lints  of  water,  and  a  tea-cupful  given  every  two  hours.  In  robust 
'ubjects,  blood-letting  maybe  practised  with  good  effects;  but  in 
!ged  or  debilitated  patients,  this  remedy  is  not  be  ventured  om 
; after  the  stomach  and  bowels  have  been  freely  evacuated,  gentle 
diaphoretics  are  to  be  employed. 

I    A  prejudice  exists  among  the  vulgar  against  every  sort  of  wet 
pplication  in  erysipelas  ;  but  I  have  witnessed  much  advantage 
(lom  the  use  of  saturnine  lotions  in  this  complaint,  and  have  never 
leen  them  do  harm. 

[\  In  severe  cases,  threatening  to  go  into  suppuration,  the  practice 
ijiy  incisions  ought  to  be  adopted.  A  transverse  incision  through 
i  be  skin  and  subcutaneous  substance  of  the  affected  lid,  if  employed 
ijkrly,  may  prevent  suppuration  and  sloughing  ;  if  later,  it  will  af^ 
i; prd  the  readiest  outlet  for  the  matter  and  disorganized  cellular 
i'lembrane.  A  warm  bread  and  water  poultice  is  to  be  applied 
i  fter  the  incision. 

f  If  a  spurious  fistula  of  the  lachrymal  sac  has  already  formed,  it 
; ;  to  be  washed  out  once  a  day  with  tepid  water,  mixed  with  a  lit- 
i  c  of  the  vinous  tincture  of  opium.  A  small  quantity  of  lint  dipped 
J  a  the  same  tincture  is  then  to  be  introduced  into  the  abscess,  but 
)|||ot  pushed  so  deep  as  to  enter  the  lachrymal  sac.  If  after  the  fis- 
litpila  has  healed,  a  blenorrhoea  of  the  sac  should  continue,  it  will 


108 

require  to  be  treated  as  explained  under  that  head,  in  a  following 
chapter. 

Mr.  Lawrence,  in  his  valuable  paper  on  the  nature  and  treatment 
of  erysipelas,  in  the  fourteenth  volume  of  the  Medico-Chirurgical 
Transactions,  has  related  two  cases  in  which  this  disease  attacked 
the  eyelids.  These  I  shall  quote,  as  they  serve  to  illustrate  both 
the  progress  of  the  complaint,  and  the  mode  of  treatjnent  by  in- 
cisions. 

Case  1.  Mr.  R.,  a  medical  student,  about  24  years  of  age,  had 
a  violent  attack  of  erysipelas  of  the  face,  apparently  from  exposure 
to  cold  air,  after  being  in  a  very  crowded  and  hot  room.  The  red- 
ness was  vivid,  with  considerable  tumefaction,  particularly  of  the 
eyelids  and  forehead.  There  was  great  pain,  headach,  restlessness 
at  night,  and  fever.  He  was  bled  to  20  ounces.  The  blood  was 
buffed.  He  was  freely  purged,  had  salines  with  antimony,  and 
low  diet.  He  was  much  relieved  by  the  loss  of  blood,  and  felt  his 
head  so  much  better,  that  he  wished  the  bleeding  repeated  the  same 
evening,  but  the  friend  who  attended  hira  would  not  comply  with 
his  desire.  On  the  next  and  following  days,  he  was  better ;  the 
swelling  and  inflammation  were  nearly  gone.  The  symptoms, 
although  still  inflammatory,  did  not  absolutely  require  the  repetition 
of  venesection,  and  he  was  averse  to  it  from  a  groundless  notion 
that  his  constitution  could  not  bear  bleeding.  He  ought,  however, 
(says  Mr.  L.)  to  have  been  bled  again.  He  took  on  the  second  day, 
four  doses  of  calomel,  each  containing  three  grains,  at  intervals  oi 
four  hours,  and  then  a  draught  of  infusion  of  senna  with  sulphate 
of  magnesia,  which  operated  very  freely.  In  two  more  days,  he 
indulged  himself  wdth  some  mutton  broth,  under  the  supposed  ne- 
cessity of  supporting  his  strength  after  the  evacuations  he  had  un- 
dergone, and  this  brought  on  a  relapse.  The  inflammation  was 
now  nearly  confined  to  the  right  upper  eyelid,  which  was  much 
swollen,  of  a  deep  red,  without  fluctuation,  and  acutely  painful, 
He  was  freely  purged  with  calomel,  followed  by  the  same  draught. 
Next  day,  the  swelling  and  pain  had  greatly  increased,  but  nc 
fluctuation  could  be  perceived.  He  urgently  requested  that  the  pari 
should  be  opened,  to  relieve  him  from  the  severe  suffering.  Mr.  L 
accordingly  made  a  transverse  incision  through  the  skin  and  tumic 
cellular  substance,  extending  the  entire  breadth  of  the  hd.  About  i. 
teaspoonful  of  white  and  almost  milky  fluid  escaped.  The  cellulai 
substance  was  swollen,  condensed,  and  had  a  whitish  appearance 
This  incision  produced  complete  relief;  the  swelling  lessened,  th( 
inflammation  stopped,  suppuration  ensued,  and  some  disorganizec 
cellular  structure  was  separated.  A  large  ulcerated  surface  was 
thus  left,  which  healed  rapidly,  without  leaving  any  trace  of  th( 
mischief  that  had  occurred. 

Case  2.  A  girl  of  the  town,  about  25,  robust,  and  of  full  habit 
came  under  Mr.  L.'s  care  in  St.  Bartholomew's  hospital,  in  th( 
summer  of  1825.    The  whole  face  was  aflfected  with  erysipelas 


109 

but  the  palpebrae  were  enormously  swollen,  deep-red,  and  shining. 
There  was  high  indammatory  fever,  with  violent  delirium  at  night. 
She  was  twice  largely  bled,  (the  blood  having  the  most  iniiamma- 
itory  character);  with  great  relief  of  the  general  symptoms,  but  wilh- 
I  out  diminishing  the  inflammation  and  pain  of  the  eyelids.  On 
I  the  second  day  after  her  admission,  an  incision  was  made  along  the 
whole  breadth  of  each  eyelid,  and  through  the  entire  depth  of  the 
inflamed  and  swollen  cellular  structure,  which  had  begun  to  slough, 
and  contained  matter  diffused  through  its  cells.  Considerable  por- 
i  tions  of  cellular  membrane  were  subsequently  detached,  and  there 
was  some  sloughing  of  the  integuments,  leaving  a  large  ulcerated 
:  and  ragged  surface  of  the  swollen  lids,  from  which  subsequent  de- 
formity might  have  been  apprehended.  The  parts,  however,  gran- 
ulated, and  healed  rapidly,  and  so  completely,  that  not  a  vestige  of 
the  extensive  mischief  remained. 


I  SECTION  IV. CARBUNCLE  OF  THE  EYELIDS. 

'  This  circumscribed,  gangrenous  inflammation  of  the  cellular 
I  membrane  is  occasionally  met  with  in  the  upper  eyelid.  The  swell- 
1  itig  is  of  a  dark  red,  or  purple  colour,  extremely  hard,  and  attended 
:  by  severe  burning  pain.  Vesicles  rise  on  its  surface,  occasioning 
:  intolerable  itching.  Ichorous  matter  is  discharged,  and  the  cellular 
!  membrane  and  skin  affected,  become  black  and  sloughy,  and  at 
;  length  fall  out.  The  cavity  left  by  the  separation  of  the  slough  gran- 
I  ulates  and  heals  up. 

Carbuncle  occurs  principally  in  old  persons,  whose  constitutions 
have  suffered  from  irregularities  in  diet. 

Opium  to   reheve   the   pain ;  bark  and  wine,   to   support   the 
strength  ;  laxatives,  and  gentle  diaphoretics,  make  up  the  general 
!  treatment. 

'  An  early  and  free  incision  into  the  tumour,  most  effectually  re- 
!  lieves  the  pain,  allows  the  matter  to  escape,  and  furthers  the  separ- 
;  ation  of  the  slough.  An  emollient  poultice  is  to  be  apphed  after 
i  the  incision  has  been  made,  and  continued  till  the  cavity  left  by  the 
I  slough  has  filled  up  by  granulation.  The  sore  is  then  to  be  dressed 
jl  with  simple  cerate. 


SECTION  V. CEDEMA  OF  THE    EYELIDS. 

This  may  depend  either  on  local  or  on  general  causes.  The 
loose  cellular  membrane  of  the  eyelids,  being  destitute  of  fat,  permits 
them  readily,  and  to  a  great  extent,  to  become  oedematous.  "We 
see  this,  sometimes  from  wounds  and  bruises  of  the  lids,  from  ery- 
sipelas, or  from  the  application  of  pressure  to  the  lower  parts  of  the 
face,  as  after  the  operation  for  harelip.     In  other  cases,  oedema  of 


110 

the  lids  is  part  of  a  general  dropsy  ;  or  it  exists  without  any  othei* 
part  of  the  body  being  dropsical,  in  adults  of  leuco-phlegnialic  consti" 
tution,  or  in  strLinioiis  children.  It  rarely  happens  that  this  affection 
occurs  spontaneous!)^,  or  without  any  known  cause,  in  an  individual 
not  labouring  under  some  other  disease. 

The  eyeUds  affected  with  03dema  are  swollen,  smooth,  pale,  semi- 
transparent,  and  soft ;  yielding  easily  to  the  pressure  of  the  finger, 
and  in  some  cases  retaining  the  mark  of  pressure  for  a  time.  Their 
motions  are  impeded,  and  llie  eyes  cannot  be  completely  opened. 

After  scarlatinous  ophthalmia,  and  after  the  too  frequent  use  of 
emollient  fomentations  and  poultices  during  different  inflammatory 
affections  of  the  e3^es,  particularly  where  poidtices  are  allowed  to  be* 
come  cold,  and  to  he  long  without  being  changed  or  removed,  we 
not  frequently  find  the  lids,  especially  the  upper  hd,  to  have  be- 
come puffy  and  oedematons. 

(Edema  of  the  eyelids  succeeding  to  a  wound  or  bruise,  to  an 
attack  of  erysipelas,  or  to  the  pressure  of  a  bandage  on  the  lower 
parts  of  the  face,  is  gradually  and  completel}'^  removed  as  the  cause 
ceases  to  operate  which  had  produced  it.  That  which  appears  in 
the  morning  in  persons  of  a  leuco-phlegmatic  habit,  diminishes  dur- 
ing the  course  of  the  day,  and  is  not  dangerous.  That  which  arises 
in  strumous  children,  or  in  adults,  without  any  evident  cause,  con- 
tinues long,  or  comes  and  goes  at  uncertain  intervals  of  time. 

It  is  only  when  this  affection  is  part  of  a  general  dropsy,  that 
it  seems  at  all  influenced  by  diuretic  medicines.  In  other  cases, 
gentle  stimulants  externally,  and  tonics  internally,  may  be  used 
with  advantage.  Bathing  the  hds  wtih  rose  water,  or  with  hme- 
water,  sharpened  with  a  little  brand}^,  will  be  found  useful.  Bags 
of  dried  aromatic  herbs,  as  chamomile  flowers,  sage,  or  rosemar}'', 
with  a  little  powdered  camphor,  suspended  from  the  brow,  so  as  to 
cover  the  hds,  are  highly  recommended.  The  bags  should  be  made 
of  old  linen,  quilted,  so  as  to  keep  the  herbs  equally  spread  out. 
When  the  oedema  is  periodic,  and  without  any  evident  cause,  a 
blister  to  the  nape  of  the  neck  will  be  found  advantageous.  In 
strumous  and  debiUtated  subjects,  chalybeates,  and  the  preparations 
of  cinchona,  are  indicated. 


SECTION  VI. — 'EMPHYSEMA  OF  THE   EYELIDS. 

A  swelling  of  the  eyelids,  produced  by  the  presence  of  air  in  their 
cellular  membrane,  may  either  be  part  of  a  general  emphysema, 
arising  from  an  injury  of  the  organs  of  respiration,  in  which  case 
the  air,  escaping  from  the  limgs,  spreads  through  the  whole  body, 
and  accumulates  chiefly  where  the  cellular  substance  is  loose  :  or 
it  may  be  the  consequence  of  a  fiactured  frontal  bone,  the  air  pass- 
ing through  the  frontal  sinus,  and  through  the  fracture,  into  the 
eyelids. 


Ill 

The  following  is  an  instance  of  the  latter  variety  of  emphysema 
of  the  eyelids.  A  lad,  of  16  years  of  age,  as  he  was  going  along 
the  street,  with  a  load,  ran  inadvertently  against  a  person  passing 
in  the  opposite  direction  ;  a  scuffle  ensued,  in  which  he  received  a 
severe  blow  immediately  over  the  right  frontal  sinus.  About  an 
hour  after,  having  occasion  to  blow  his  nose,  the  eyelids  and  parts 
adjacent  became  immediately  inflated,  so  as  completely  to  close  the 
eye  ;  and  he  felt  the  air  rush,  he  said,  into  those  parts.  On  being 
admitted  into  Guy's  Hospital,  under  the  care  of  Mr.  Morgan,  the 
eyelids  were  much  distended,  and  so  closely  approximated,  that 
they  could  not  be  separated  by  any  voluntary  effort  of  the  patient ; 
the  eyebrow  was  also  puffed  up,  and  the  cellular  membrane  be- 
tween the  ear  and  the  orbit  was  in  the  same  state  of  emphysema. 
The  parts  were  not  at  all  painful  on  pressure  ;  they  yielded  a  crack- 
ling sensation  to  the  touch,  and  were  free  from  discoloration.  The 
supposed  seat  of  the  fracture  was  at  a  small  distance  above  the  su- 
percilliary  ridge,  where  a  flight  depression,  but  no  crepitus,  could 
be  felt.  The  globe  of  the  eye  was  perfectly  natural.  The  treat- 
ment adopted  was  very  simple.  Two  small  incisions  were  made 
through  the  integuments,  about  the  eighth  of  an  inch  behind  the 
external  angle  of  the  frontal  bone,  which  allowed  the  air  to  escape. 
The  swelling  subsided  in  24  hours,  leaving  the  eye  and  surround- 
ing soft  parts  in  a  perfectly  healthy  condition.* 

The  same  plan  of  incision  through  the  integuments  is  adopted 
when  the  eyelids  are  greatly  disteiided,  in  cases  of  universal  em- 
physema. It  is  merely,  of  course,  a  palliative  remedy ;  the  com- 
plete removal  of  the  disease  depending  on  the  healing  up  of  the 
injured  part  of  the  lungs,  or  windpipe.  Even  in  cases  of  fractured 
frontal  bone,  the  evacuation  of  the  diflfused  air  is  merely  palliative  ; 
and  till  the  consolidation  of  the  bone,  the  emphysema  will  be  lia- 
ble to  return. 


SECTION  VII. INFLAMMATION  OF  THE  EDGES  OF  THE  EYELIDS, 

OR  OPHTHALMIA  TARSI. 

The  edges  of  the  eyelids  and  roots  of  the  eyelashes  are  subject 
to  a  peculiar  inflammation,  of  a  very  tedious  character.  It  is  this 
disease  which  produces  bleared  eyes,  and  so  often  destroys  entirely 
the  eyelashes.  If  long  neglected,  it  becomes  inveterate,  and  almost 
incurable. 

The  seat  of  this  disease  appears  to  be  the  Meibomian  follicles, 
their  apertures  running  along  the  edge  of  the  lid,  the  neighbouring 
portion  of  conjunctiva,  and  the  glands  at  the  roots  of  the  cilia. 

The  disease  has  received  various  names,  and  different  views 
have  been  entertained  of  its  nature.  As  itchiness  is  one  of  its  symp- 
toms, it  has  been  called  scabies  palpebrarum,  and  psorophthalmia  ; 

*  Lancetj  Vol.  x.  p.  31.     London,  1826. 


112 

and  some  have  even  supposed,  that  in  certain  cases,  at  least,  it  con- 
sists in  an  eruption  of  itch,  caused  either  by  inoculation  or  by  re- 
percussion. Comparing  it  to  eruptions  of  the  hairy  scalp,  it  has 
been  called  by  some,  tinea  ciliorum ;  Avhile  others  have  regarded  it 
as  herpetic  or  porriginous.  Mr.  Lawrence  denies  that  this  com- 
plaint ever  partakes  of  the  nature  of  psora.  '^I  am  in  the  habit," 
says  he,  "of  seeing  numerous  cases  of  itch  in  its  most  aggravated 
form,  but  I  have  not  seen  inflan)mation  either  of  the  eye  or  lids  in 
these  instances  ;  neither  during  nor  subsequent  to  the  itchy  erup- 
tion. Where  the  body  has  been  covered  with  itch  to  the  greatest 
degree,  I  never  saw  any  kind  of  ophthalmic  disease  attributable  to 
this  specific  cause  ;  indeed,  it  is  well  known  that  the  head  and  face 
are  peculiarly  exempt  from  this  loathsome  disorder,  and  that  they 
very  rarely  suffer,  even  when  all  the  rest  of  the  body  is  thickly  be- 
set with  vesicles  and  pustules  of  scabies.  Nor  has  the  rapid  cure 
of  the  itch  by  suitable  treatment,  in  instances  of  its  most  extensive 
prevalence,  had  any  injurious  effect,  within  my  experience.  I  have 
neither  seen  ophthalmia,  nor  other  affections  of  the  organ,  from 
the  reti-opulsion  of  scabies."  * 

Local  symptoms.  The  most  striking  symptom  of  this  disease, 
is  the  gluing  together  of  the  edges  of  the  eyelids  in  the  morning, 
by  means  of  a  glutinous  and  superabundant  secretion  from  the 
Meibomian  follicles  and  neighbouring  portion  of  the  conjunctiva. 
This  gummy  matter,  incrusting  during  sleep,^  binds  the  eyelashes 
together,  so  that  the  patient  is  obliged  either  to  soften  it  before 
opening  his  eyes  in  the  morning,  or  to  use  considerable,  and  even 
painful  effort,  for  their  separation.  This  is  not  accomphshed 
without  tearing  out  some  of  the  eye-lashes,  which  is  followed  by 
little  abscesses  and  ulcers  at  their  roots.  Frequently  removed  in 
this  way,  and  their  bulbs  injured  or  destroyed,  they  are  apt  ta 
cease  from  being  reproduced,  or  to  become  feeble  and  dw^arfish. 

In  this  disease,  the  Meibomian  secretion,  which  is  naturally 
bland,  and  very  small  in  quantit)^,  serving  merely  to  smear  the 
edges  of  the  eyelids,  so  as  to  conduct  the  mucus  of  the  conjunctiva 
and  the  tears  towards  the  puncta  lachrymalia,  becomes  profuse, 
and  is  changed  into  a  puriform  matter.  This  matter  of  itseli 
causes  constant  irritation,  and  frequent  itchiness  of  the  eye  and 
eyelids,  and  adhering  to  the  eyelashes,  prevents  the  little  ulcers 
from  heaHng  which  arise  at  their  roots.  The  tears,  excited  bj 
the  irritation,  are  discharged  more  frequently  than  natural,  and 
being  no  longer  conducted  along  the  edges  of  the  lids  towards  the 
puncta  lachrymalia,  as  they  are  in  health,  but  dropping  over  upon 
the  cheek,  chafe  and  excoriate  the  integuments.  The  consequence 
is,  that  we  frequently  find  this  disease  attended  wMth  much  swefl- 
ing  and  redness  of  the  eyelids,  and  the  skin  of  the  cheeks  inflamed, 
ulcerated,  or  covered  with  scabs.     Not  unfrequently,  the  conjunc- 

♦  Lectures  in  the  Lancet,  Vol.  x.  p.  322.    London,  1826. 


j  113 

tiva  lining  the  lids  is  inflamed;  one  or  more  of  the  Meibomian 
follicles  greatly  distended,  so  as  to  form  a  kind  of  hordeolum  ;  or 
;the  whole  substance  of  the  eyelids  much  thickened,  hard,  and  callous. 
I  The  local  symptoms  of  inflammation  of  the  edges  of  the  eyelids, 
•vary  considerably  in  different  instances  ;  they  vary  in  severity,  in 
obstinacy,  in  the  appearances  of  the  matter  discharged,  and  even 
!in  the  seat  of  the  principal  morbid  changes,  for  in  some  the  Mei- 
bomian follicles,  in  others  the  ciliary  glands,  or  bulbs  of  the  eye- 
lashes, are  the  parts  chiefly  affected. 

;  There  are  two  events  which  are  apt  to  take  place,  when  this 
'disease  has  continued  long,  and  been  neglected.  The  one  is  a 
ipartial  or  total  obliteration  of  the  Meibomian  apertures,  along  the 
inner  margin  of  one  or  both  eyelids.  In  this  case,  which  may  be 
regarded  as  incurable,  the  edge  of  the  affected  lid  becomes  rounded 
loff,  instead  of  being  angular,  and  generally  the  eyelashes  are  al- 
iinost  altogether  wanting.  The  other  event  is  eversion  of  the 
lower  lid,  from  the  contracted  state  of  the  skin,  consequent  to  the 
! healing  up  of  the  excoriated  cheek.  Not  unfrequently  these  two 
sequelee  go  together. 

,  Trichiasis,  or  inversion  of  the  eyelashes,  distichiasis,  or  mis- 
, placed  eyelashes,  and  even  inversion  of  the  lids,  must  also  be  enu- 
inierated  among  the  effects  of  long  continued  ophthalmia  tarsi. 
Those  who,  being  affected  with  this  disease,  get  into  the  habit  of 
iDpening  their  eyes  but  very  partially,  or  in  whom  the  edges  of  the 
'Ms  have  suffered  from  repeated  ulcerations,  are  most  subject  to  in- 
iP'ersion. 

I  Constitutional  si/mj)tom,s.  Inflammation  of  the  edges  of  the 
•jyelids  is  much  more  frequent  in  children  than  in  adults.  In  al- 
inost  every  case,  the  patient  presents  undoubted  marks  of  a  stru- 
nous  constitution  ;  the  functions  of  the  skin,  and  of  the  digestive 
)igans  are  disordered,  and  the  general  health  impaired.  Not  un- 
i'requently  we  find  this  disease  associated  with  strumous  conjuncti- 
;ritis,  enlarged  lymphatic  glands,  swollen  upper  hp,  sore  ears, 
ucalled  head,  tumid  abdomen,  paleness  and  looseness  of  the  skin, 
estlessness  during  the  night,  and  morning  perspirations. 
i  Causes,  Ophthalmia  tarsi  is  rarely  a  primary  disease.  It  much 
Inore  frequently  takes  its  origin  from  measles,  small-pox,  scarlatina, 
catarrhal  ophthalmia,  ophthalmia  neonatorum,  strumous  oph- 
;  halmia,  or  porrigo.  In  all  these  diseases,  the  Meibomian  follicles 
\re  apt  to  become  affected  with  inflammation,  and  while  the  other 
symptoms  which  attend  them  subside,  or  totally  disappear,  the 
)phthahnia  tarsi  is  exceedingly  apt  to  remain.  When  this  dis- 
i;ase  appears  to  be  primary,  cold,  impure  air,  smoke,  and  filthi- 
less,  operating  directly  on  the  eyelids,  are  among  the  most  fre- 
i^uent  exciting  causes  ;  while  the  strumous  constitution  aflfords  its 
I  lid  in  perpetuating  the  complaint,  or  at  least  in  favouring  relapses, 
[n  adults,  we  frequently  find  the  habitual  use  of  wine  and  spirits 
0  keep  up  this  affection  of  the  eyelids. 
15 


114 

Treatment.  The  treatment  of  this  disease  cousists,  1st,  Iii 
such  remedies  as  are  hkely  to  abate  the  inflammation,  upon  which 
the  whole  train  of  symptoms  depends,  to  sooth  the  pain  and  itching", 
and  prevent  the  bad  eflects  of  the  gluing  together  of  the  lids: 
2dly,  In  the  use  of  stimulants,  with  the  view  either  of  deadening 
the  excoriated  and  ulcerated  parts,  or  of  strengthening  the  debiU- 
tated  eyelids  :  and,  3dly,  In  constitutional  remedies. 

1.  The  first  direction  to  be  given  to  the  patient,  or  to  his  attend- 
ant, is  never  to  attempt  to  open  the  eyes  in  the  morning,  till  the 
gluey  matter  is  completely  softened,  so  that  the  eyelids  may  sepa- 
rate without  pain,  and  without  injuring  the  eyelashes.  For  this 
purpose,  a  teaspoonful  of  milk,  with  a  bit  of  fresb  butter  melted  in 
it,  may  be  employed  for  smearing  the  lids,  rubbing  it  with  the  fingei 
gently  along  the  agglutinated  e3^elashe3.  A  piece  of  soft  sponge, 
wrung  out  of  hot  water,  is  then  to  be  held  upon  the  eyelids  for 
some  minutes ;  after  which  the  patient  will  find  the  eyelids  yield 
without  pain,  to  the  least  effort  he  makes  lo  open  them.  With  the 
finger  nail,  the  whole  of  the  gummy  matter  is  immediately  to  be 
removed ;  and  should  it  happen,  that  during  the  day,  or  towards 
evening,  there  is  any  reappearance  of  it,  the  same  plan  must  be 
adopted  for  its  entire  removal.  This  is  absolutely  necessarj^,  be- 
cause as  long  as  the  gummy  matter  is  allowed  to  remain,  no  appli- 
cation of  eye-water  or  salve  can  be  of  any  use,  as  it  never  gets  into 
contact  with  the  seat  of  the  complaint. 

2.  The  first  indication  is  further  to  be  promoted  by  the  use  of  a 
warm  decoction  of  chamomile  flowers  as  a  fomentation,  after  the 
lids  have  been  thus  completely  freed  from  their  morbid  secretion. 

3.  Scarification  of  the  palpebral  conjunctiva,  the  apphcation  o; 
leeches  to  the  external  surface  of  the  lids,  and  to  the  neighbouring 
skin,  blisters  behind  the  ears,  and  to  the  nape  of  the  neck,  and  laxa- 
tives, are  also  to  be  occasionally  employed,  for  the  purpose  of  sub- 
duing the  inflammation. 

4.  Cataplasms  of  bread  and  water,  enclosed  in  a  small  liner 
bag,  and  laid  over  the  eyelids^  during  the  night,  are  often  useful  ir 
aggravated  cases. 

5.  A  caustic  issue  in  the  neck,  or  arm,  is  often  attend  with  bene- 
fit. Indeed,  it  rarely  happens  that  much  good  can  be  effected 
without  this  remedy,  in  those  cases  in  which  the  lids,  from  long 
neglect,  have  become  greatly  thickened  and  callous,  a  state  whict 
is  sometimes  termed  tylosis. 

6.  Next  in  importance  to  the  careful  removal  of  the  morbic 
secretion,  and  the  use  of  hot  fomentations  in  the  morning,  is  the 
application  of  a  stimulating  salve  to  the  edges  of  the  eyelids  at  bed- 
time. The  salves  which  have  been  found  most  useful,  are  the  rec 
precipitate,  and  the  mild  nitrate  of  mercury.  The  latter  is  prepared 
according  to  the  formula  in  the  Pharmacopoeia,  but  is  usually  stiL 
farther  reduced  in  strength.  The  former  consists  of  12  grains  o: 
red  precipitate,  carefully  levigated  into  an  impalpable  orange  powder 


115 

'  lud  mixed  with  one  ounce  of  fresh  butter,  or  of  soft  cerate.  Abotit 
;  he  bulk  of  a  hemp  seed,  of  one  or  other  of  these  salves  is  to  be 
nelted  at  the  end  of  the  finger,  and  rubbed  into  the  roots  of  the 
eyelashes,  and  along  the  Meibomian  apertures,  every  night,  or 
svery  second  night,  according  to  the  severity  of  the  symptoms, 
ind  the  effects  produced.  If  much  irritation  follows  the  application 
>f  the  salve,  once  every  second  night  will  be  sufficiently  often,  a 
ittle  simple  cerate,  softened  by  an  addition  of  axunge,  being  used  on 
:he  alternate  nights.  In  some  cases  we  are  obliged  to  reduce  the 
trength  of  the  red  precipitate  salve,  while  in  other  instances,  20 
grains  to  the  ounce  will  be  borne  with  advantage. 

Salves  are  often  employed  for  the  cure  of  ophthalmia  tarsi,  with- 
»ut  almost  any  effect,  from  these  two  necessary  particulars  not 
:)eing  known  or  attended  to,  namely,  that  the  salve  is  not  to  be 
}  meared  over  the  diseased  crust,  but  applied  only  after  the  lids  are 
reed  of  every  particle  of  the  morbid  secretion,  and  that  it  is  not  to 
ie  pencilled  softly  on,  but  pressed,  by  repeated  friction,  into  the 
iiiseased  roots  of  eyelashes,  and  into  the  mouths  of  the  Meibo- 
nian  follicles.  Unless  it  smarts  considerabl}^,  it,  in  general,  does 
ittle  good. 

Other  salves  besides  those  above  mentioned,  are  sometimes  em- 
ployed for  the  cure  of  this  disease ;  especially  Janin's,  which  consists 
)f  30  grains  of  the  white  precipitate  of  mercury  to  an  ounce  of  unc- 
Lious  substance.  In  old  people  and  in  those  incurable  cases  in  which 
he  Meibomian  apertures  are  obliterated,  this  salve  answers  better, 
lerhaps,  than  any  other.  The  ointment  of  oxide  of  zinc,  that  of 
arbonate  of  lead,  and  various  others,  have  also  been  used.  In 
lorriginous  cases,  a  mixture  of  sulphur  with  the  mild  nitrate  of 
iaercury  ointment,  will  be  found  very  effectual. 
;  Not  unfrequently  we  meet  with  slight,  but  very  irritable  cases  of 
iphthalmia  tarsi,  in  which  not  even  the  mildest  salve  can  be  borne. 
■ ''omentations,  with  poppy  decoction,  or  simply  with  warm  water, 
fford  most  relief  in  such  cases. 

■  7.  During  the  course  of  the  day,  it  is  proper  to  bathe  the  eyelids 
;  arefuUy  with  a  solution  of  from  one  to  tv/o  grains  of  corrosive  sub- 
imate  in  eight  ounces  of  distilled  water.  This  colly rium  is  to  be 
:  sed  tepid  ;  and  after  the  outside  and  edges  of  the  hds  are  well 
paked  with  it,  by  means  of  a  bit  of  hnen,  it  may  be  allowed  to  run 
1  upon  the  eye,  so  as  to  get  into  contact  with  the  inner  surface  of 
le  lids,  which  in  this  disease  is  always  more  or  less  inflamed. 
:  Other  coUyria  may  also  be  employed,  as  weak  brandy  and  water, 
I  solution  of  sulphate  of  zinc,  or  of  sub-borate  of  soda. 
I  8.  Should  little  ulcers  be  present  along  the  edges  of  the  lids,  they 
;re  to  be  touched  with  the  lunar  caustic  solution,  or  with  the  solid 
uitras  argenti. 

1  When  the  lids  are  greatly  thickened  and  indurated,  their  edges 
liuch  incrusted,  and  the  roots  of  the  eyelashes  ulcerated,  it  has 
■een  recommended  to  extract  all  the  eyelashes,  and  then  touch  the 


116 

whole  diseased  surface  lightly  with  a  pencil  of  lunar  caustic.  This 
has  a  great  effect  in  heaUng  the  ulcers,  and  diminishing  the  swell- 
ing. In  a  few  days  the  caustic  may  be  repeated.  Three  or  four 
repetitions  are  generally  sufficient.  Mr.  Lawrence,  who  recom- 
mends this  practice,  states,  that  there  is  another  inducement  to  ex- 
tract the  cilia.  Those  which  fall  out  by  ulceration  are  never  re- 
placed, because  the  bulb  which  secretes  the  hair  is  destroyed,  but 
when  they  are  plucked  out,  they  are  afterwards  restored. 

9.  As  the  obstinacy  of  ophthalmia  tarsi  almost  invariably  depends 
on  a  faulty  constitution,  tonics  and  alteratives  are  always  necessary. 
The  tonics  chiefly  to  be  depended  on  are  the  sulphate  of  quina, 
other  preparations  of  bark,  the  mineral  acids,  the  carbonas  ferri 
preecipitatus,  and  chalybeates  in  general.  These  are  to  be  given  in 
appropriate  doses,  and  continued  for  a  length  of  time.  The  prin- 
cipal alterative  employed  in  the  cure  of  this  disease,  is  mercury,  and 
perhaps  the  form,  which  on  the  whole  is  the  best,  is  Plummer's  pill. 
l\hether  alteratives  or  tonics  are  employed,  a  dose  of  laxative  medi- 
cine, as  sulphate  of  magnesia,  infusion  of  senna,  or  powdered  rhu- 
barb and  jalap,  ought  to  be  occasionally  interposed. 

10.  The  regulation  of  the  patient's  diet  is  essential  for  the  cure 
of  this  disease.  Care  is  to  be  taken  lest  the  stomach  be  overloaded 
at  bedtime,  or  disturbed  by  indigestible  or  improper  food  during  the 
day  ;  for  if  this  be  permitted,  the  morbid  secretion  becomes  more 
copious,  and  a  greater  degree  of  irritation  and  inflammation  is  in- 
duced. 

11.  The  warm  bath,  with  sea-water,  if  it  can  be  had,  is  an  ex- 
cellent remedy  in  this  disease. 

12.  Pure  air,  and  regular  exercise,  are  to  be  recommended. 

13.  The  clothing  of  those  affected  with  this  disease,  ought  to  b€ 
particularly  attended  to.  A  delicate  child  is  easily  chilled.  The 
skin,  stomach,  liver,  and  bowels,  are  thereby  disordered ;  and  an 
attack  of  this  disease,  or  of  strumous  conjunctivitis,  is  a  frequent 
concomitant.  These  diseases  are  always  difficult  of  cure  when  the 
weather  is  damp  and  cold. 

14.  Sleep  at  early  hours  is  of  great  consequence.  Hardly  anj 
thing  tends  more  to  confirm  this  affection  of  the  lids,  than  sitting 
up  late  at  night. 

Prognosis.  So  obstinate  is  ophthalmia  tarsi  in  many  instances 
that  we  are  frequently  asked,  if  it  will  ever  be  cured.  The  answei 
depends  on  the  state  of  the  Meibomian  apertures,  and  on  the  per- 
severance of  the  patient,  or  his  friends,  in  the  means  of  cure.  If 
from  neglect,  the  mouths  of  the  Meibomian  follicles,  in  numbei 
about  30  on  the  edge  of  each  eyelid,  are  partially,  or  totally  obliter 
ated,  so  that  the  skin  covering  them  is  smooth  and  shining,  and  no 
thing  can  be  pressed  out  from  them,  the  case  is  incurable.  Thf 
patient,  for  life,  must  pay  attention  that  the  hds  do  not  get  worse. 
He  must  use  Janin's  or  some  other  salve,  every  night;  and  follow 
the  general  directions  regarding  diet,  clothing,  and  exposure,  alrea- 


117 

dy  laid  down.  If  the  Meibomian  apertures  are  patent,  however 
niuch  inflamed  and  disfigured  the  eyelids  are  by  the  disease,  the 
case  is  perfectly  curable  by  perseverance ;  but  even  after  the  symp- 
toms appear  completely  gone,  the  remedies  will  require  to  be  con- 
tinued for  months  at  least.  The  approach  of  puberty  exercises  its 
influence  over  this,  as  over  other  strumous  diseases. 

SequelcB.  As  important  effects  of  ophthalmia  tarsi,  may  be  men- 
tioned, tylosis,  or  chronic  thickening  of  the  whole  substance  of  the 
lid  ;  lippitudo,  excoriation  of  the  edges  of  the  lids,  or  bleared-eyes  ; 
obhteration  of  the  Meibomian  follicles,  the  cause  of  incurable  lippi- 
tudo ;  madarosis,  loss  of  the  eyelashes  ;  ectropium,  from  the  con- 
tracted state  of  the  skin,  consequent  to  the  healing  up  of  the  excor- 
iated lids  ;  trichiasis,  or  inversion  of  the  eyelashes  ;  distichiasis,  or 
misplaced  eyelashes ;  entropium.  from  repeated  ulcerations  of  the 
edges  of  the  lids,  and  contraction  of  the  cartilages.  Several  of  these 
sequelae  I  shall  take  up  separately.  The  disease  described  by  Cel- 
sus  under  the  name  of  lippitudo,  appears  to  have  been  catarrhal 
conjunctivitis. 


SECTION  VIII. HORDEOLUM  AND  GRANDO. 

A  hordeolum,  or  stye,  is  nothing  more  than  a  little  bile,  about 
the  size  of  a  barley-corn,  projecting  from  the  edge  of  the  eyelid. 

Symptoms.  The  swelling  is  of  a  dark  red  colour,  very  hard, 
attended  at  first  by  itching,  and  afterwards  by  a  great  degree  of 
pain  in  proporton  to  its  small  size.  The  tension  and  exquisite 
sensibility  of  the  skin  which  covers  the  edge  of  the  eyelids,  serve 
to  explain  the  vehemence  of  the  pain.  The  inflammation  spreads, 
in  some  degree,  to  the  conjunctiva,  and  the  motions  of  the  lids  are 
impeded.  In  delicate  irritable  subjects,  fever  and  restlessness  are 
excited.  The  swelling  suppurates  slowly,  and  at  last  points  and 
bursts.  After  discharging  a  small  quantity  of  curdy  pus,  and  dis- 
organized cellular  membrane,  it  subsides  and  disappears.  If  it 
heals  up  with  any  of  the  matter  remaining  within  it,  the  disease  is 
apt  to  return,  or  to  degenerate  into  a  hard  white  tumour,  called 
grando,  from  its  resemblance  to  a  hailstone,  which  having  once 
formed,  shows  no  disposition  to  undergo  any  farther  change. 
Grando  also  lesults  occasionally  from  an  indurated  hordeolum 
which  has  not  advanced  to  suppuration. 

Causes.  Hordeolum  is  most  frequent  in  strumous  subjects.  It 
frequently  depends  on  late  hours,  the  use  of  spirituous  liquors,  and 
disordered  bowels. 

Treatment.  In  the  incipient  stage,  cold  applications  are  to  be 
used,  as  vinegar  and  water,  solution  of  acetas  plumbi,  or  an  iced 
poultice.  If  suppuratiun  appears  to  be  advancing,  a  warm  bread 
and  water  poultice,  enclosed  in  a  httle  bag  of  linen,  or  a  roasted  ap- 
ple poultice,  is  to  be  applied.     If  slow  of  bursting,  the  abscess  may 


118 

be  opened  with  the  point  of  a  lancet.  The  pus  and  destroyed  cel- 
lular membrane  are  to  be  pressed  out,  and  the  poultice  continued. 
It  sometimes  happens,  that  the  sloughy  cellular  membrane  is  slow 
of  coming  away,  in  which  case  the  cavity  may  be  touched  with  a 
sharp  pencil  of  lunar  caustic,  or  with  a  probe  dipped  in  sulphuric 
acid,  after  which  the  cavit)^  soon  closes. 

In  the  commencement  of  hordeolum,  an  emetic,  followed  next 
day  b}^  a  purge,  will  be  found  useful. 

In  those  who  are  liable  to  frequent  attacks  of  hordeolum,  we 
must  recommend  temperance,  and  early  going  to  bed. 

Grando  is  commonly  single  ;  in  other  cases,  there  are  several 
tumours  of  this  sort  even  on  the  same  eyelid.  Attem.pts  to  discuss 
them  by  promoting  absorption,  are  generally  fruitless  ;  but  occasion- 
ally by  friction,  or  by  the  application  of  stimulating  salves,  they 
are  induced  to  suppurate.  The  best  plan  of  treatment,  is  to  lay 
the  grando  open  with  the  lancet,  press  out  its  contents,  and  touch 
the  interior  of  the  cyst  with  the  pencil  of  lunar  caustic. 


SECTIOX  IS. PHLYCTENULA  AXD    MILIUM. 

Semitransparent  vesicles,  or  phh'ctenulae.  filled  with  watery  fluid, 
are  frequently  observed  on  the  edges  of  the  eyelids,  especially  at  the 
inner  canthus,  sometimes  single,  often  in  groups,  varying  in  size 
from  that  of  a  mustard  seed,  to  that  of  a  pea.  They  are  to  be  laid 
hold  of  with  a  pair  of  hooked  forceps,  and  snipped  off  with  the  scis- 
sors. 

Small  white  tumours,  like  millet  seeds,  containing  a  suet-like 
substance,  are  often  observed  between  the  Meibomian  apertures 
and  the  cilia.  They  are  to  be  opened  with  the  point  of  a  lancet, 
and  their  contents  pressed  out. 


SECTION  X. "WARTS    OX  THE    EYELIDS. 


"W"arts  are  not  uncommon  to  the  external  surface  of  the  eyelids, 
and  sometimes  grow  from  their  edges.  They  are  to  be  removed 
by  ligature,  or  the  application  of  caustic,  according  to  the  breadth 
of  their  attachment.  I  have  known  the  removal  of  a  wart  on  one 
of  the  lids  blamed  for  bringing  on  a  warty  or  fungous  state  of  the 
conjunctiva. 


t 


SECTION  XI. ENCYSTED  TU3I0URS  OF  THE  EYELIDS,  AND  EYE- 
BROW. 

There  are  two  kinds  of  encysted  tumours  of  the  eyelids,  which 
we  meet  with  not  unfrequently. 

1.  The  first,  which  is  an  extremely  common  disease,  contains  a 


119 

gelatinous  matter,  and  is  often  spoken  of  by  the  name  of  chalazion, 
although  this  word  is  merely  the  Greek  term  for  grando.  This 
gelatinous  encysted  tumour  bears  considerable  resemblance  to  a 
hordeolum,  only  it  is  not  situated  on  the  edge  of  the  lid,  but  gene- 
rally at  some  considerable  distance  from  it.  The  skin  covering 
the  tumour  is  red  and  elevated ;  the  tumour  is  at  first  perfectly 
moveable,  but  after  a  time  becomes  more  fixed  to  the  cartilage  of 
the  lid  ;  on  everting  the  lid,  we  find  its  inner  surface  inflamed,  and 
often  depressed,  even  in  the  early  stage  ;  and  after  the  disease  has 
continued  for  a  considerable  time,  we  find  a  small  fungus-like  pro- 
jection through  the  cartilage,  and  through  the  conjunctiva  lining 
the  lid,  corresponding  to  the  point  which  previously  had  been  de- 
pressed. 

This  sort  of  tumour  is  met  with  most  frequently  in  the  upper 
lid,  sometimes  in  the  lower,  or  in  both  at  the  same  time.  In  some 
cases  more  than  one  such  tumour  are  situated  in  the  same  lid. 

The  digestive  organs  of  those  who  are  troubled  with  this  disease 
are  almost  uniformly  out  of  order ;  the  stomach  acid  and  flatulent ; 
the  bowels  slow,  and  the  stools  morbid.  In  incipient  cases,  the 
farther  progress  of  the  tumour  may  often  be  checked  by  alterative 
doses  of  blue  pill,  laxatives,  and  tonics,  especially  steel  and  bark. 
Under  this  treatment,  I  have  seen  many  such  tumours  disperse 
entirely.  Friction  over  the  tumour  with  camphorated  mercurial- 
ointment  is  also  useful. 

When  the  tumour  still  continues,  or  advances,  it  is  necessary  to 
remove  it  by  operation.  Scarpa  strongly  recommends  this  to  be 
done  on  the  inside  of  the  lid.  I  was  in  the  way  of  extirpating 
such  tumours  by  an  incision  through  the  integuments,  and  orbicu- 
laris palpebrarum ;  but  I  have  for  some  time  satisfied  myself  with 
a  simpler,  but  not  less  effectual  mode  of  cure.  I  evert  the  affected 
lid,  puncture  the  tumour  freely  with  the  lancet  pushed  through  the 
cartilage,  and'  press  out  the  gelatinous  contents.  For  some  days 
the  cyst  continues  to  keep  up  an  appearance  as  if  the  tumour  were 
still  present,  although  lessened  in  size :  but  gradually  the  sweUing, 
redness,  and  other  signs  of  the  disease,  go  off  entirely. 

2.  The  other  sort  of  tumour  of  the  eyelids  is  steatomatous.  It 
is  more  distinctly  circumscribed  than  the  former,  and  the  integu- 
ments covering  it,  instead  of  being  red,  are  whiter  than  natural. 
It  is  firmer  to  the  touch,  not  at  all  painful,  and  does  not  appear  to 
be  connected  with  any  disordered  state  of  the  digestive  organs.  If 
dependent  on  any  constitutional  cause,  steatomatous  tumours  of  the 
eyelids  are  of  strumous  origin.  I  have  seen  a  crop  of  them  disap- 
pear from  the  eyelids  of  a  strumous  child,  during  the  use  of  the 
sulphate  of  quina.  In  general,  howevei',  we  are  obliged  to  extir- 
pate such  tumours,  by  a  transverse  incision  through  the  integu- 
ments. They  appear  to  lie  exterior  to  the  orbicularis  palpebrarum, 
so  that  in  several  instances,  after  dividing  the  skin,  I  have  been 
able,  by  pressure,  to  bring  away  the  tumour  enclosed  in  its  cyst, 
without  any  farther  dissection. 


120 

In  extirpating  a  sarcomatous,  or  any  other  tumour  from  the 
eyelid?,  care  must  be  taken,  lest  the  cyst,  being  adlierent  to  the  car- 
tilage, we  remove  part  of  the  latter,  or  in  any  way  materially  injure 
it.  Leaving  the  adherent  part  of  the  cyst  behind  is  to  be  preferred 
to  injuring  the  cartilage. 

The  eyebrow,  and  especially  its  temporal  extremity,  is  a  frequent 
seat  of  encysted  tumours.  These  are  generally  melicerous,  or  stea- 
tomatous.  A  firm  scirrhus-like  tumour,  which  is  very  apt  to  return, 
unless  completely  extirpated,  is  also  met  with  under  the  integuments 
of  the  eyebrow.  All  these  tumours  are  to  be  removed  in  the  usual 
manner,  and  the  edges  of  the  wound  brought  together  by  stitches 
and  adhesive  plaster. 


SECTION  XII. CALLOSITY  OF  THE  EYELIDS. 

Tylosis  is  a  kind  of  callosity,  arising,  as  has  heen  already  ex- 
plained, from  neglected  opthalmia  tarsi. 

There  are  two  other  varieties,  however,  of  thickening  and  indu- 
ration &f  the  eyelids,  which  merit  attention. 

The  one  is  attended  with  redness,  attacks  generally  the  upper 
eyeUd,  and  seems  to  have  its  chief  seat  external  to  the  cartilage. 
The  whole  length  of  the  eyelid  is  commonly  affected  ;  but  in  some 
cases,  merely  a  part,  and  not  unhequently  the  neighbourhood  of 
the  papilla  lachrymahs.  I  have  never  seen  this  variet}^  of  callosity 
end  in  suppuration  nor  ulceration.  It  slowly  increases,  and  then 
becomes  stationary,  and  is  little,  if  at  all,  affected  by  any  remedies. 
The  application  of  leeches,  friction  with  camphorated  mercurial  oint- 
ment, laxatives^  and  alteratives  internally,  I  have  generaUy  found 
fruitless  in  this  complaint. 

The  other  variety  of  callosity  attacks  the  lower  lid  more  fre- 
quently than  the  upper,  is  seated  more  on  the  inner  surface  of  the 
affected  lid,  is  of  a  white,  or  slightly  yellow  colour,  rriore  or  less  tu- 
berculaied,  and  apt  to  end  in  ulceration.  From  its  appearance,  its 
occurring  generally  in  old  people,  its  intractable  nature,  and  its 
ending  in  ulceration,  we  are  apt  to  confound  it  with  scirrhus,  with 
which,  however^  it  is  by  no  means  identical.  I  have  watched  some 
cases  of  this  variety  of  callosity  for  a  number  of  years,  and  although 
the  indiiration  and  swelling  did  not  subside,  yet,  by  care  to  avoid 
injuring  the  part,  by  soothing  applications  to  the  edges  of  the  lids, 
and  the  use  of  the  red  precipitate  ointment,  and  lunar  caustic  solu- 
tion, to  the  ulcerated  points,  the  complaint  has  been  kept  at  bay, 
and  the  operation  of  removing  the  affected  lid,  which  could  not  have 
been  done  without  sacrificing  the  eye,  prevented.  Fowler's  solution, 
internally,  has  appeared  to  me  to  assist  in  checking  the  progress  of 
this  complaint. 

Although  hitherto  successful  in  warding  off  the  progress  of  this 
disease,  yet  I  can  easily  conceive,  that  both  it  and  the  other  variety 
of  callosity^  may  be  brought,  by  neglect,  to  such  a  state,  as  shall 


121 

warrant  the  removal  of  the  affected  lid.  There  is  one  thing,  how- 
ever, regarding  the  removal  of  either  eyelid  for  this  disease,  or  for 
any  disease,  which  must  be  attended  to.  If  either  lid  is  removed, 
the  eyeball  is  necessarily  left  exposed,  and  is  very  apt  to  become 
irritated  and  inflamed.  We  ought  to  state  this  to  the  patient.  Such 
an  event  wiU,  of  course,  much  more  readily  follow,  if  it  be  the  upper 
lid  which  is  removed ;  and,  perhaps,  it  would  be  the  best  plan,  if  the 
patient  would  submit  to  it,  to  remove  the  eyeball  along  with  that  lid. 
When  both  eyelids  are  removed,  this  ought  always  to  be  done,  even 
although  the  eyeball  is  as  yet  not  at  all  affected. 


SECTION    XIII. CANCER    OF    THE    EYELIDS. 

'  The  disease,  vulgarly  called  Eating  Cancer  of  the  Face,  is  not 
m  unfrequent  one.  It  often  begins  on  the  lower  eyelid.  It  slowly 
consumes  the  skin  and  the  muscles,  till  it  destroys  not  merely  the 
id,  but  a  great  part  of  the  cheek,  enters  the  orbit,  attacks  the  eye, 
md  at  length  proves  fatal.  Dr.  Jacob,  in  some  excellent  observa- 
ions  which  he  has  published*  on  this  disease,  remarks,  that  its 
•characteristic  features  are  the  extraordinary  slowness  of  its  progress, 
he  peculiar  condition  of  the  edges  and  surface  of  the  ulcer,  the 
;omparatively  inconsiderable  suffering  produced  by  it,  its  being 
ncurable  unless  by  extirpation,  and  its  not  affecting  the  neighbour- 
ng  lymphatic  glands. 

Symptoms  and  Progress.  We  sometimes  meet  with  this  dis- 
;ase  while  yet  confined  to  the  lower  lid.  We  find  it  thickened, 
md  more  or  less  of  its  edge  ulcerated.  In  some  instances,  the 
»uter  angle  of  the  lids  is  the  seat  of  the  disease.  It  appears  not 
mfrequently  to  commence  in  the  form  of  a  wart,  or,  perhaps,  more 
orrectly,  it  is  nothing  else  than  a  wart,  which,  being  picked  off 
Is^ith  the  finger,  leaves  a  raw  surface,  exposed  to  the  irritation  of 
be  tears,  and  apt  to  spread  by  ulceration.  In  other  cases,  the 
rigin  of  this  disease  appears  to  be  an  encysted  tumour,  which, 
llowed  to  burst  on  the  inside,  or,  it  may  be,  on  the  outside,  of  the 
yelid,  becomes  irritated,  and  is  thus  induced  to  assume  the  ulcerous 
r  cancerous  action.  An  encysted  tumour,  immediately  under  the 
kin,  picked  with  the  finger,  sometimes  a  mere  scratch  of  the  edge 
j  f  the  eyelid,  a  blow,  or  the  irritation  of  an  old  cicatrice,  such  as 
hat  which  results  from  small-pox,  may  give  rise  to  cancer  of  the 
yelids. 

The  irritation  of  the  tears  has,  in  every  case,  much  to  do  with 

le  production  of  this  disease.     They  are  excited  to  flow  by  the 

isistenceof  the  ruffled  wart,  or  burst  encysted  tumour,  and  again,  in 

leir  turn,  they  prevent  the  sore  (simple,  probably,  in  the  first  in- 

Icance,)  from  healing ;  till  at  length  it  assumes  what  we  term  a 

jpecific,  or  malignant  character. 

ij 

'  *  Dublin  Hospital  Reports.     Vol.  iv.  p.  233.     Dublin,  1827. 

16 


122 

The  progress  of  the  ulceration  in  this  disease  is  generally  very 
slow.  I  have  known  it  for  years  confined  to  the  lower  eyelid, 
without  making  almost  any  advance ;  nay,  occasionally  contract- 
ing, and  partially,  or  even  totally,  cicatrizing :  again  to  commence, 
and  spread  for  a  certain  space,  and  again  to  heal.  It  has  been 
known  to  remain  for  ten,  nay,  for  20  years,  without  making  much 
progress.  In  other  cases,  hov/ever.  the  eyelids  are  entirely  destroyed, 
the  eyeball  exposed,  so  as  to  become  inflamed,  and  at  last  to  burst, 
the  lachrymal  passages  laid  open,  the  bones  of  the  orbit  deprived  ol 
their  periosteum,  and  rendered  carious,  while  the  ulcer,  spreading 
down  tlie  face,  eats  away  the  cheek,  lays  bare  the  teeth,  and  at  last 
forms  one  common  and  hideous  opening  along  with  the  mouih 
Yet,  even  after  it  has  produced  the  most  shocking  deformity,  its 
progress  is  sometimes  stayed  for  months  or  for  years,  so  that  thf 
individual  lives  with  his  eyelids  entirely  gone,  the  eyeball  dissectet 
from  almost  all  its  connexions,  and  perhaps  half  of  the  face  de- 
stroyed. 

The  appearances  of  the  disease  are  different  at  different  times 
Sometimes  it  presents  a  scab,  which,  on  being  removed,  is  sue 
ceeded  by  another  ;  but  generally,  the  sore  exposed,  on  removinc 
these  successive  scabs,  is  found  to  be  slowly  enlarging,  growing 
deeper,  and  becoming  more  painful.  When  the  sore  becomes  ai 
open  ulcer,  too  large,  too  irregular,  and  too  active,  to  be  covered  b} 
a  scab,  we  observe  that  it  eats  away  all  parts  indiscriminately 
which  may  be  in  the  direction  in  which  it  is  spreading.  In  on( 
of  the  cases  which  have  fallen  under  my  care,  the  ulceration  o 
the  skin  appeared,  after  a  time,  entirely  to  cease,  while  the  disease 
proceeded  deep  into  the  oibit  by  the  inner  side  of  the  eyeball 
Not  unfrequently,  we  find  that  the  progress  of  the  ulceration  i. 
checked  at  one  part  of  the  circumference  of  the  sore,  while  it  i 
still  advancing  at  another  ;  or  that  the  whole  sore  assumes,  for  i 
time,  a  healing  action.  When  this  is  the  case,  the  pain  become 
less,  the  edges  become  smooth  and  glossy,  and  even  the  part  \\nth 
in  the  edges  becomes  smooth,  or  is  gradually  covered  with  florid 
healthy-looking  granulations.  These  are  occasionally  firm  ii 
texture,  and  remain  unchanged  in  size  and  form  for  a  length  o 
time.  Veins  of  considerable  size  are  seen  ramifjing  over  the  sur 
face  of  the  sore.  If  it  heals  up,  it  does  so  in  patches,  which  ar< 
hard  and  smooth,  and  marked  with  the  same  venous  ramifications 
When  it  again  begins  to  ulcerate,  it  loses  its  florid  hue,  and  glis 
tening  and  granulating  appearance.  Often  there  is  present  in  thi 
disease,  a  tendency  to  actual  reparation,  as  well  as  to  cicatrization 
there  is  a  deposition  of  new  material,  and  a  fiiUing  up  in  certaii 
places,  which  gives  an  uniformity  to  the  surface,  which  otherwis' 
would  be  very  irregular.  The  healing  which  occurs  in  this  dis 
ease  may  take  place  on  any  part  of  the  surface,  whatever  be  th 
original  structure.  In  a  case  which  Dr.  Jacob  had  under  his  care 
the  eyeball  itself^  denuded  as  it  was  by  ulceration,  became  partially 
cicatrized. 


123 

The  skin  in  the  vicinity  of  the  sore  is  not,  in  general,  much 
thickened,  or  discoloured,  differing  in  these  respects  from  the  dis- 
ease called  lupus,  or  noli  me  tangere,  which  we  see  attack  the 
point  of  the  nose,  and  sometimes  spread  to  the  face.  The  edges  of 
the  sore  in  cancer  of  the  eyelids,  are  occasionally  formed  into  a  range 
of  elevations  or  tubercles. 

The  veins  which  ramify  over  the  surface  of  the  sore  are  apt  to- 
give  way,  when  considerable  bleeding  sometimes  takes  place. 
From  the  surface  itself  of  the  ulcer,  there  is  no  considerable  bleed- 
ing. When  haemorrhage  does  occur,  it  arises  from  the  superficial 
veins  giving  way  and  not  from  sloughing  or  ulceration  opening 
the  vessels.  Sometimes  the  surface  of  the  sore  assumes  a  dark 
gangrenous  appearance,  arising  from  effusion  of  blood  beneath. 

The  discharge  from  the  surface  of  the  sore,  is  not,  in  general,  of 
the  description  called  unhealthy,  or  sanious,  but  yellow,  and  of 
proper  consistence  ;  neither  is  there  more  foetor  than  from  the 
healthiest  sore,  if  the  parts  be  kept  perfectly  clean,  and  dressed 
frequently.  Mr.  Travers,  however,  whose  short  notice  of  this 
disease  differs  in  several  particulars  from  the  more  elaborate  de- 
scription of  Dr.  Jacob,  mentions,  that  it  is  attended  by  an  unhealthy 
discharge.* 

There  is,  in  general,  httle  or  no  fungous  growth,  nor  indeed 
any  elevation,  except  at  the  edges,  and  even  this  is  sometimes  very 
inconsiderable. 

Dr.  Jacob  has  represented  the  sufferings  of  persons  labouring 
under  this  disease  as  not  very  acute.  He  says,  there  is  no  lanci- 
nating pain,  and  that  the  principal  distress  appears  to  arise  from 
the  exposure,  by  ulceration,  of  nerves,  and  other  highly  sensible 
parts.  In  the  instances  which  he  had  met  with,  the  disease,  at 
the  worst  period,  did  not  incapacitate  the  patients  from  following 
their  usual  occupations.  One  gentleman,  who  laboured  under  this 
disease  for  nine  years,  and  who  died  from  a  different  cause,  was 
cheerful,  says  Dr.  J.,  and  enjoyed  the  comforts  of  social  life  after 
the  ulceration  had  made  the  most  deplorable  ravages.  These 
statements  of  Dr.  J.  may  be  received  with  implicit  confidence. 
Yet  it  must  be  noticed,  that  when  the  ulceration  affects  the  infra- 
orbitary  and  supra-orbitary  nerves,  very  severe  suffering  is  experi- 
enced. I  have  also  witnessed  the  most  excruciating  pain  when 
the  eyeball  was  attacked  with  inflammation,  in  consequence  of  ex- 
posure from  destruction  of  the  lids.  The  eyeball,  in  these  circum- 
stances, ulcerates  and  bursts,  the  lens  and  vitreous  humour  are 
evacuated,  and  sometimes,  till  this  emptying  of  the  eye  is  effected, 
the  pain  is  agonizing.  I  have  known  the  lens  hang  in  view  for 
several  days,  producing  great  irritation,  which  ceased  after  it  fell 
out.  In  such  a  case,  it  is  probable  that  the  iridal  nerves  convey 
the  impressions  which  are  so  painful. 

*  Synopsis  of  the  Diseases  of  the  Eye,  p.  100.  London,  1820. 


124 

When  this  disease  extends  to  the  periosteum,  the  bones  of  the 
orbit  are  laid  bare,  and  become  carious.  They  sometimes  exfoU- 
ate  in  small  scales,  but  more  generally  they  are  destroyed,  as  the 
soft  parts  are,  by  an  ulcerative  process.  This  may  proceed  to  such 
a  length,  as  to  expose  the  cavity  of  the  nostril  through  the  de- 
stroyed orbit,  or  even  to  lay  open  the  cavity  of  the  cranium  through 
the  orbitary  plate  of  the  frontal  bone.  Inflammation  of  the  dura 
mater  and  of  the  brain  will,  in  this  case,  soon  put  an  end  to  the 
patient's  sufferings  ;  although  more  commonly  he  dies  worn  out 
by  fever,  and  sometimes  by  diarrhcea. 

Diagnosis.  Modern  researches  into  the  nature  of  malignant  tu- 
mours and  ulcers,  and  especially  those  carried  on  by  Professor 
Burns,  Mr.  Hey,  Mr.  Abernethy,  Mr.  Wardrop,  M.  Breschet,  Mr. 
Fawdington,  and  others,  have  established  at  least  this  fact,  that 
there  are  essential  differences  between  a  number  of  diseases  formerly 
confounded  under  the  appellation  of  cancer.  The  improbability 
that  structures  so  extremely  different  as  the  mamma,  the  uterus,  the 
glans  penis,  the  lip,  the  eyelids,  and  the  eyeball,  should  fall  into 
the  same  kind  of  degeneration,  had  formerly  entirely  escaped  atten- 
tion. It  is  probable  that  a  still  more  accurate  discrimination  may 
be  made  between  the  various  malignant  disorders  of  these  parts. 
We  are  now  at  no  loss  in  distinguishing  cancer  from  spongoid 
tumour,  or  spongoid  tumour  from  melanosis,  but  with  regard  to 
the  malignant  ulcerations  which  attack  different  parts  of  the  face, 
there  still  exists  a  considerable  degree  of  confusion. 

Dr.  Bateman,  Mr.  S.  Cooper,  and  others,  seem  to  consider  this  dis- 
ease of  the  eyelids  as  noli  me  tangere,  which,  according  to  Sir  A. 
Cooper,  is  an  ulceration  of  the  cutaneous  follicles.  Dr.  Jacob,  how- 
ever, ol3serves,  that  this  disease  is  evidently  pecuhar  in  its  nature, 
and  is  to  be  confounded  neither  with  genuine  carcinoma,  nor  with 
the  disease  called  lupus  or  noli  me  tangere.  From  the  former,  it 
is  distinguished  by  the  absence  of  lancinating  pain,  fungous  growth, 
foetor,  slough,  haemorrhage,  and  contamination  of  lymphatics ; 
from  the  latter,  by  the  absence  of  the  furfuraceous  scabs,  and  in- 
flamed margins,  as  well  as  by  the  general  appearance  of  the 
ulcer,  its  history,  and  progress.  It  is  equally  distinct  from  the 
ulcer  with  cauliflower-like  fungous  growth,  which  occasionally 
attacks  old  cicatrices.  We  sometimes  see  syphilitic  chancre  on 
the  eyelids ;  but  from  this  the  present  disease  may  generally  be 
distinguished  by  its  slow  progress,  by  its  not  causing  so  much 
swelling  of  the  integuments  round  the  ulcer,  and  by  the  history 
of  its  origin. 

Treatment. — 1.  Alterative  and  other  medicines.  It  is  a  ques- 
tion of  great  importance,  whether  this  disease  can  be  removed 
by  any  other  means  than  the  knife,  or  powerful  escharotics.  Dr. 
Jacob's  opinion  is,  that  it  bids  defiance  to  all  remedies  short  of 
extirpation.  '•'  I  have  tried,"  says  he,  "  internally,  alterative 
mercurials,  antimony,  sarsaparilla,  acids,  cicuta,  arsenic,  iron,  and 


125 

other  remedies :  and  locally,  simple  and  compound  poultices,  oint- 
ments, and  washes,  containing  mercury,  lead,  zinc,  copper,  arsenic, 
sulphur,  tar,  cicuta,  opium,  belladonna,  nitrate  of  silver,  and  acids, 
without  arresting  for  a  moment  the  progress  of  the  disease.  I 
have  indeed  observed,  "  adds  he,"  that  one  of  those  cases  which 
is  completely  neglected,  and  left  without  any  other  dressing  than 
a  piece  of  rag,  is  slower  in  its  progress  than  another  which  has 
had  all  the  resources  of  surgery  exhausted  upon  it." 

Now,  although  these  remarks  of  Dr.  Jacob  are  perhaps  rather 
too  sweeping,  yet  it  cannot  be  denied,  that  both  internal  and  ex- 
ternal remedies  have  extremely  little  control  over  this  disease, 
:  and  that  though  it  may  for  a  time  seen  to  mend  under  their  in- 
Ifluence,  it  has  rarely  if  ever  been  known  to  be  thoroughly  cured, 
1  except  by  destroying  the  part  with  caustic,  or  removing  it  by  the 
}  knife. 

Arsenic  internally,  and  carbonate  of  iron,  sprinkled  on  th»  sore, 
are  the  means  which,  I  believe,  do  most  good.     I  have  known 
I  them  to  operate  as  paUiatives,    but    never    to    produce  a  radical 
I  cure  ;  and  therefore  I  should  never  trust  to  them. 

2.  Caustics  and  cautery.  These  are  certainly  not  much  to 
be  recommended.  They  are  more  painful,  and  not  so  sure  as 
the  knife.  They  do  occasionally  succeed  when  the  disease  is  lim- 
ited to  the  outer  surface  of  the  eyelid,  never  when  the  whole 
thickness  is  aflfected. 

Dr.  Jacob  mentions,  that  a  woman  in  the  incurable  Hospital 
at  Dublin,  had  had  a  burning  cancer  plaster  applied  several  times, 
and  17  years  after,  the  arsenical  composition  called  Plunkett's 
powder,  without  any  good  effect.  A  gentleman,  to  whose  case 
he  repeatedly  refers,  had  the  sore  healed,  when  it  was  very  small, 
by  the  free  application  of  lunar  caustic,  under  the  care  of  Mr. 
Travers.  It  broke  out  again,  however,  and  spread,  without  inter- 
ruption, until  it  destroyed  the  lids  and  globe  of  the  eye.  Under 
these  circumstances,  he  in  despair,  submitted  himself  to  a  quack, 
who,  bold  from  ignorance,  gave  a  full  trial  to  escharotics.  He 
repeatedly  applied  what  was  understood  to  be  a  solution  of  muriate 
of  mercury,  in  strong  nitric  acid,  and  in  a  short  time  excavated  a 
hideous  cavern,  extending  from  the  orbitary  plate  of  the  frontal 
bone  above,  to  the  floor  of  the  maxillary  sinus  below,  and  from 
the  ear  on  the  outside,  to  the  septum  narium  within.  The  unfor- 
tunate gentleman  survived,  the  disease  continuing  to  preserve,  in 
every  respect,  its  original  charactei-, 

3.  Extirpation  hy  the  knife.  That  when  the  disease  exists  in 
a  situation  which  admits  of  extirpation,  the  sooner  this  is  done  the 
better,  and  that  this  can  be  effected  best  by  the  knife,  admits  of  no 
doubt. 

The  effects  of  removing  one  or  both  lids,  have  already  been  ex- 
plained. The  upper  lid  will,  to  a  certain  extent,  and  much  more 
than,  a  priori,  we  could  expect,  supply  the  loss  of  the  lower  lid  ; 


126 

but  if  the  upper  is  removed,  the  eyeball  also  requires  to  be  taken 
away,  else  it  will  speedily  be  destroyed  by  inflammation. 

The  incisions  ought  to  be  made  into  the  sound  parts.  If  both 
lids  are  affected,  the  lower  ought  first  to  be  extirpated,  then  the  up- 
per, and  last  the  eyeball. 


SECTION    SIV. SYPHILITIC  ULCERATION    OF    THE    EYELIDS. 

I  have  seen  only  two  cases  of  this  sort.  The  one  was  a.priraary 
sore  on  the  edge  of  the  lower  lid,  in  a  girl  of  the  town  ;  the  other,  a 
secondary  sore,  also  on  the  lower  lid,  of  an  old  man,  a  patient  at  the 
Eye  Infirmary.  He  acknowledged  having  been  treated,  some  time 
before,  for  a  primaiy  affection,  else  I  should  have  probably  experi- 
enced some  difficulty  in  deciding  lespecting  the  nature  of  the  case. 
The  lid  was  much  swollen  and  everted,  its  conjunctiva  greatly  in- 
flamed, and  on  the  external  surface  of  the  lid  there  was  a  deep  ul- 
cer, painful,  and  spreading  towards  the  inner  canthus.  The  skin 
round  the  ulcer  w^as  of  a  dark  red  colour.  I  ordered  him  two 
grains  of  calomel,  and  one  of  opium,  night  and  morning.  Not- 
withstanding which,  he  returned  in  five  days  with  another  smaller 
ulcer  near  the  punctum  lachrymale  of  the  same  lid.  The  conjunc- 
tiva, covering  the  inner  edge  of  the  cornea,  was  also  in  a  state  of 
ulceration.  The  first  ulcer  of  the  lid  was  extending  upwards  and 
inwards,  but  at  other  parts  its  edge  appeared  inclined  to  skin.  The 
ulcer  of  the  cornea  was  touched  with  the  lunar  caustic  solution,  and 
a  carrot  poultice  ordered  to  the  lid.  Nine  days  after  this,  the  ever- 
sion  and  thickening  of  the  lid  had  become  considerably  less  ;  the 
first  ulcer  had  coalesced  with  that  near  the  punctum,  but  was  gran- 
ulating and  filling  up.  Soon  after  this,  the  mouth  became  soi'e, 
and  the  ulcer  contracted  and  healed.  The  mercury  was  stopped 
and  resumed  according  to  the  state  of  the  mouth,  and  a  decoction 
of  elm-bark  was  given.  As  the  lid  continued  to  be  everted  after 
the  ulcer  had  cicatrized,  the  thickened  and  inflamed  conjunctiva 
was  scarified,  and  the  red  precipitate  salve  was  applied  every  even- 
ing ;  after  which,  the  lid  completely  resumed  its  place,  scarcely  any 
deformity  being  caused  by  the  cicatrice,  and  no  opacity  left  on  the 
cornea. 

Syphilitic  ulceration  of  the  eyelids  generally  occurs  either  on  the 
edge,  going  on  to  destroy  at  once  the  skin,  the  cartilage,  and  the  conjunc- 
tiva; or  on  the  integuments,  proceeding  rapidly  to  form  a  deep  and 
foul  excavation  ;  but  in  some  cases  the  ulcer  commences  on  the  in- 
side of  the  lid,  spreading  over  a  considerable  extent  of  the  conjunc- 
tiva. Mr.  Lawrence  mentions  his  having  seen  some  cases,  in  which 
foul  ulcers  of  this  kind,  having  been  developed  in  the  upper  lid, 
spread  over  the  whole  of  its  inner  surface,  without  appearing  exter- 
nally. In  one  case,  the  sore,  he  believes,  would  not  have  been 
discovered,  if  he  had  not  been  directing  his  attention  some  time  be- 


127 

fore  to  the  subject,  so  that  he  was  led  to  evert  the  eyeUd,  when  he 
discovered  a  syphilitic  ulcer  as  large  as  a  sixpence.* 

I  remember  M.  Cullerier  mentioning  in  his  lectures  at  the  Hopi-' 
tal  des  VinerienSy  that  chancres  of  the  eyelids  were  sometimes 
brought  on  by  a  kiss  from  an  infected  person,  and  in  other  cases  by 
the  virus  being  conveyed  on  the  finger.  Secondary  sores  on  the 
eyelids  are  generally  attended  by  other  secondary  symptoms,  and 
particularly  by  ulcerations  of  the  throat. 

Both  the  primary  and  the  secondary  cases  will  be  most  effectually 
relieved  by  the  use  of  mercury.  Either  to  mistake  the  nature  of 
the  ulceration,  or  to  trifle  with  it  in  the  non-mercurial  way,  would 
be  to  expose  the  patient  to  the  loss  of  the  hd,  and  even  of  the  eye. 


SECTION  XV. N^VUS  MATERNUS,    AND  ANEURISM    BY  ANASTO- 
MOSIS, OF   THE  EYELIDS. 

Neevus  maternus,  or  mother's  mark,  occurs  not  unfrequently  on 
the  eyelids,  and  especially  on  the  upper.  It  is  sometimes  but  little 
raised  above  the  level  of  the  integuments,  through  which  there  ap- 
pears  a  collection  of  dilated  blood-vessels.  In  other  cases,  the  nee- 
vus  is  prominent,  of  a  deep  red  colour,  smooth  like  a  cherry,  or 
granulated  like  a  raspberry.  Some  nsevi,  though  vivid  at  birth, 
gradually  fade  and  disappear  ;  some  remain  stationary  through  life, 
although  varying  in  intensity  of  colour  at  different  seasons,  and 
according  to  the  different  degrees  of  activity  in  the  circulation ; 
while  a  third  set  begin  to  grow,  sometimes  immediately  after  birth, 
and  sometimes  from  incidental  causes  at  a  subsequent  period,  and 
from  small  beginnings,  -become  large  and  formidable  vascular  tu- 
mours, partaking  of  the  nature  of  the  disease  first  accurately  de- 
scribed  by  Mr.  John  Bell,  under  the  name  of  aneurism  by  anastomo- 
sis, readily  bursting,  and  giving  rise  to  impetuous  and  alarming 
haemorrhages,  which,  if  they  do  not  prove  suddenly  fatal,  materially 
injure  the  health  by  frequent  depletion  of  the  system.! 

There  appears  sufficient  ground  for  believing,  that  tumours  of 
this  sort  are,  in  some  cases,  venous,  and  in  others  arterial.  The 
latter  are  characterised  by  their  vivid  colour,  high  temperature,  rapid 
and  dangerous  course,  continual  and  distinct  pulsation,  and  the  great 
dilatation,  sudden  bendings,  and  violent  throbbing  of  the  arteries 
which  feed  them ;  while  the  former  are  livid,  cold,  without  pulsa- 
tion, and  slow  in  their  progress.  Both,  however,  are  subject  to  be- 
come suddenly  tense,  as  if  ready  to  burst,  when  the  patient  is  ex- 
posed to  much  heat,  indulges  in  violent  exercise,  or  is  under  the 
influence  of  mental  excitement.  Both,  but  especially  the  arterial, 
communicate  a  peculiar  dough-like  impression  when  laid  hold  of 

*  Lectures  in  the  Lancet,  Vol.  x.  p.  324.     London,  1826. 
_  t  See  Bell's  Principles  of  Surgery,  Vol.  i.  p.  456.     Edin.  1801.     Bateman's  Synop- 
sis of  Cutaneous  -Diseases,  p.  329.    London,  1819. 


128 

with  the  fingers,  yielding  slowly  to  pressure,  till  they  seem  empty 
and  flaccid,  then  filling  up  almost  immediately  to  their  former  size. 
Another  distinction  of  some  importance  is,  that  of  cutaneous  and 
subcutaneous  nsevi.  In  the  former,  the  tumour  appears  to  be  seated 
entirely  in  the  skin ;  while  in  the  latter,  the  integuments  can  be 
pinched  up  from  off  the  tumour,  and  do  not  seem  to  be  in  them- 
selves affected. 

It  is  not  to  be  denied,  that  aneurisms  by  anastomosis,  after  hav- 
ing increased  to  a  certain  degree,  sometimes  cease  to  enlarge,  and 
thenceforth  continue  stationary,  or  gradually  shrink  till  scarcely  a 
vestige  remains.  In  some  cases,  ulceration  and  sloughing  occur 
spontaneously  in  these  growths,  destroying  them  in  part,  consoli- 
dating the  remainder,  and  preventing  them  from  increasing.  In 
other  cases,  some  very  shght  cause  of  irritation,  as  a  trifling  bruise, 
will  excite  a  mere  stain-like  speck,  or  a  minute  livid  tubercle,  into 
an  uncontrollable  state  of  diseased  action. 

It  is  fortunate,  then,  that  a  method  of  cure  for  nsevus  maternus, 
in  its  early  stage,  has  been  discovered,  which  seems  to  be  equally 
sure  and  simple.  The  principle  upon  v/hich  this  method  of  cure 
depends,  is  the  destruction,  by  suppuration,  of  the  cellular  substance 
surrounding  the  anastomosing  vessels,  thereby  insuring  the  obliter- 
ation of  the  vessels  themselves.  The  means  by  which  inflamma- 
tion of  the  neevus  is  excited  is  the  vaccine  lymph,  and  the  sooner 
after  birth  the  cure  is  attempted  the  better.  With  a  lancet  already 
charged  with  the  recent  lymph,  slight  scratches  are  to  be  made 
upon  the  surface,  and  into  the  circumference  of  the  neevus,  at  reg- 
ular distances  from  each  other.  As  soon  as  the  bleeding  has  ceased, 
additional  lymph  is  to  be  introduced ;  and  then  over  the  whole 
surface  of  the  tumour,  a  bit  of  linen,  saturated  with  the  same  fluid, 
is  to  be  applied,  and  retained  for  several  hours.  In  the  usual  time 
the  vesicles  appear,  and  in  general  the  nsevus  gradually  subsides, 
leaving  scarcely  any  mark  behind.  Each  vesicle  produces  a  de- 
gree of  adhesive  inflammation,  which  induces  an  occlusion  of  the 
nseval  cells  and  vessels  only  to  a  certain  distance  around  it ;  and 
therefore  it  is  necessary  to  inoculate  the  surface  of  the  tumour  at 
such  distances  that  the  inflammation  of  one  shall  coalesce  with  that 
of  another,  and  thus  produce  the  cure  of  the  whole.  If  the  child 
has  been  vaccinated  in  the  common  way,  previously,  perhaps,  to 
the  nsevus  attracting  much  notice,  this  plan  of  cure  will  rarely  suc- 
ceed ;  but  ought  still  to  be  tried.  If  the  child  has  not  been  vaccin- 
ated, this  operation,  besides  curing  the  nsevus,  will  affect  the  con- 
stitution as  inoculation  in  the  common  way. 

We  owe,  it  appears,  this  method  of  removing  nsevus,  to  Mr. 
Hodgson,  of  Birmingham.*  It  has  now  been  adopted  by  a  num- 
ber of  other  practitioners,  and  among  these  by  Dr.  Young,  of  Glas- 
gow, who  has  published  a  short  account  of  two  cases  in  which  he 

*  Medico-Chirurgical  Review,  Vol.  vii.  p.  280.  London,  1827.  Lancet,  "Vol,  xi-L 
p.  760.     London,  1827. 


129 

tried  it.  His  first  patient  was  a  child,  three  months  old,  who  pre- 
sented a  roundish  tumour,  nearly  as  large  as  a  sixpence,  on  the 
right  side  of  the  chin.  It  was  considerably  elevated  above  the  sur- 
rounding skin,  and  had  a  purplish  colour.  At  birth  it  was  no 
bigger  than  a  split  pea.  Around  the  border  of  the  tumour,  as  well 
as  all  over  its  surface,  minute  punctures  were  made,  and  vaccine 
lymph  freely  applied.  In  ten  days  the  whole  disease  was  involved 
in  one  pustule,  but  when  this  became  incrusted,  and  was  thrown 
off,  there  still  remained  a  dark  coloured,  prominent,  and  diseased 
surface.  Another  suppuration  succeeded,  and  a  third  ;  when  at  the 
3nd  of  five  weeks,  a  complete  cure  was  effected,  no  trace  of  the  djs- 
3ase  remaining,  nor  mark,  farther  than  what  follows  vaccination  on 
.1  healthy  part.  This  cure  was  hardly  completed,  when  another 
little  child  was  brought  to  Dr.  Y.,  with  a  nsevus  advancing  rapidly, 
and  occupying  the  middle  and  edge  of  the  upper  eyelid.  The  same 
process  was  followed  with  very  similar  results.  A  cure  was  effected, 
Dut  after  a  very  tedious  festering  and  ulceration.* 

When  vaccination  has  failed,  or  when  vaccine  lymph  cannot  be 
procured,  some  other  stimulating  fluid  may  be  tried,  inserting  it 
into  the  nsevus  in  the  same  way  as  we  do  the  lymph.  A  strong 
solution  of  tartrate  of  antimony  may  be  used  for  this  purpose  ;  or  a 
pustular  eruption,  affecting  the  nsevus  to  a  sufficient  depth,  might 
probably  be  excited  by  rubbing  it  with  the  tartrate  of  antimony 
ointment,  or  covering  it  with  an  antimonial  plaster.  It  is  likely 
that  the  vaccine  lymph  produces  no  specific  effect  upon  this  sort  of 
lumour,  but  operates  merely  by  the  inflammation  which  it  excites, 
and  that  any  other  stimulant,  of  proportionate  strength,  and  ap- 
plied with  equal  care,  would  be  followed  by  nearly  the  same  result. 
Mr.  Wardrop  has  repeatedly  employed  pure  potash  for  this  purpose, 
applying  it  to  the  neevus  so  as  to  produce  an  eschar.  In  some  in- 
stances, the  eschar,  on  falling  out,  has  been  found  to  comprehend 
the  whole  diseased  mass ;  while,  at  other  times,  the  separation  of 
the  eschar  has  been  followed  by  ulceration,  v/hich  destroyed  the 
remainder  of  the  tumour. t 

It  is  evident,  that  we  cannot  expect  large  neevi  to  be  cured  in 
this  way.  If  they  have  readied,  perhaps,  three  quarters  of  an 
inch  diameter,  and  are  prominent  and  active,  the  hgature  or  the 
knife  must  be  emplo)^ed  for  their  cure.  The  former  will  generally 
be  preferred  in  cases  in  which  the  eyelids  are  the  seat  of  the  dis- 
ease. The  tumour  being  laid  hold  of  with  the  flnger  and  thumb, 
or  with  a  pair  of  forceps,  so  as  to  raise  it  as  much  as  possible  from 
the  proper  substance  of  the  lid,  a  curved  needle,  armed  with  two 
strong  waxed  linen  threads,  is  to  be  passed  through  its  base  from 
above  downwards,  so  as  to  divide  the  tumour  into  two  portions, 
«ach  of  which  is  to  be  grasped  by  its  own  ligature.     The  ligatures 

*  Glasgow  Medical  Journal,  Vol.  i.  p.  93.     Glasgow,  1828. 
t  Lancet,  Vol.  xi.  p.  653.     London,  1827. 

17 


130 

being  drav/n  tight,  and  secured  by  a  double  knot,  in  the  course  of 
48  hours  the  tumour  will  have  entirely  lost  its  vitality,  so  that  it 
may  be  sliced  off,  and  the  ligatures  removed.  A  poultice  is  then 
to  be  applied,  and  continued  till  the  exposed  surface  granulates  and 
heals.  Some  very  extensive  and  irregular  nsevi,  stretching  partly 
over  the  eyelids,  may  require  more  than  two  ligatures. 

Nsevi.  going  on  into  the  state  of  aneurisms  by  anastomosis,  have 
occasionally  been  removed  by  excision.  This  is  an  effectual,  but 
by  no  means  a  very  safe  mode  of  cure.  The  bleeding  attendant 
on  the  removal,  by  the  knife,  of  even  small  naevi,  is  profuse,  and 
dangerous  in  the  young  patients,  who  are  the  most  frequent  sub- 
jects of  the  operation.  When  the  morbid  growth  itself  is  cut,  a 
powerful  gush  of  arterial  blood  takes  place,  which  can  hardly  be 
restrained,  and  is  not  exphcable  by  any  thing  hitherto  ascertained 
respecting  the  nature  of  these  structures.  Although  the  knife  keeps 
clear  of  the  tumour,  there  is,  in  general,  very  serious  haemorrhage. 
so  that  in  removing  even  small  nsevi  in  this  way,  alarm  has  justl} 
been  excited  for  the  life  of  the  patient,  and  the  recovery  of  strength 
and  colour  has  been  very  tedious. 

Mr.  John  Bell  relates  the  case  of  a  gentleman,  of  about  25  years 
of  age,  who  had  an  aneurism  by  anastomosis  upon  his  forehead 
where  it  had  been  grov/ing  for  some  years.  It  began  with  a  smal 
spot  like  a  pimple,  of  the  size  of  a  pea,  and  was,  when  he  consultec 
Mr.  B.,  of  the  size  of  an  egg.  It  was  seated  close  upon  the  eye 
brow,  and  at  its  commencement  was  so  small,  and  so  little  trouble- 
some, that  it  was  believed  to  be  a  pimple,  brought  on  by  a  tight 
hat.  When  it  had  attained  the  size  of  a  sparrow's  egg,  the  patien 
thought  he  felt  occasional  pulsation  in  it.  He  consulted  a  surgeon 
who  found  the  pulsation  distinct,  pronounced  it  to  be  an  aneurism 
and  advised  that  it  should  be  cut  out.  The  patient  delayed,  auc 
was  recommended  by  some  one  to  try  pressure.  This  producing 
pain,  but  no  good  eflfect.  he  let  the  aneurism  grow  as  it  pleased  fo: 
five  years.  The  operation  was  now  decided  on.  The  tumour  ap 
peared  to  derive  its  blood  from  tv/o  arteries  ;  one,  a  branch  of  th< 
temporal,  enlarged  and  tortuous,  which  passed  into  the  upper  enc 
of  the  tumour,  while  the  other,  coming  from  within  the  orbit,  en 
tered  the  lower  end.  These  two  arteries  and  the  intermediate  tu 
mour  beat  in  concert,  and  very  strongly. 

Under  the  apprehension  that  the  disease  was  merely  an  enlarget 
artery,  the  surgeon  first  passed  a  ligature  under  the  arterial  brand 
coming  li'om  the  orbit,  and  tied  it ;  but  this  did  not  abate  the  pul 
sation  of  the  aneurism.  He  next  tied  the  temporal  branch,  bu 
the  pulsation  remained  unaffected.  The  tumour  was  then  laic 
open  in  its  whole  length.  It  bled  very  profusely.  A  needle,  armec 
with  a  ligature,  was  stuck  into  its  centre,  where  there  was  one 
artery  larger  than  the  rest ;  but  from  all  the  surface  besides  there 
was  one  continual  gush  of  blood.  The  hsemorrhage  was  repressed 
and  the  wound  bound  up  with  a  compress  and  bandage.     It  healec 


I  131 

I 

slowly,  the  ligature  came  away  with  difficulty,  the  pulsation  began 
a^ain,  and  by  the  time  the  wound  was  healed,  the  tumour  was  as 
large  as  before  the  operation.  For  nine  months  the  patient  allowed . 
'  it  to  go  on  unmolested,  and  then  consulted  Mr.  B.  It  was  of  a  regu- 
'lar  oval  form,  and  across  the  middle  of  it  ran  the  scar  of  the  opera- 
tion. The  spot  was  not  purple  on  its  surface,  but  was  covered  by 
a  firm,  sound  skin.  The  two  arteries  were  felt  pulsating  with 
great  force ;  and  w^hen  the  patient  was  heated,  stooped,  or  breathed 
hard,  the  pulsations  of  the  tumour  became  very  strong.  By  this 
time  it  was  affected  also  with  pain.  Mr.  B.  knew,  that  if  he  cut 
within  the  active  circle  of  the  tumour,  he  should  have  innumerable 
'blood-vessels  to  contend  with.  He  therefore  resolved  to  cut  out  this 
'aneurism,  not  to  cut  into  it.  He  made  an  oval  incision,  which 
comprehended  about  a  fourth  part  of  the  surface  of  the  tumour, 
I  dissected  the  skin  of  each  side  down  from  it  rapidly,  went  down 
to  the  root  of  the  tumour,  and  turned  it  out  from  the  bone.  It  bled 
furiously  during  the  operation,  but  the  moment  it  was  turned  out, 
Ihe  bleeding  ceased.  The  two  arteries  were  tied,  the  eyebrow  was 
'brought  nicely  together,  and  the  incision  healed  in  ten  days.  The 
lumour  appeared  a  perfect  cellular  mass,  like  a  piece  of  sponge 
soaked  in  blood.* 

'  This,  then,  is  a  striking  example  of  the  subcutaneous  arterial 
aneimsm  by  anastomosis,  and  of  the  mode  of  cure  by  excision. 
'The  following  case,  related  by  Mr.  Allan  Burns,  furnishes  an  in- 
istance  of  the  cutaneous  and  venous  variety  of  this  disease. 
I  A  middle-aged,  stout  man,  presented  a  large,  livid,  compressible 
jtumour,  in  the  vicinity  of  the  right  orbit.  The  swelling  had  ex- 
I'isted  from  birth,  was  sometimes  more  distended  than  at  others,  but 
'ivas  seldom  productive  of  pain,  except  when  injured,  on  which 
loccasion  it  poured  out  a  considerable  quantity  of  fluid  blood.  It 
'never  pulsated  nor  throbbed ;  but  during  exertion,  or  walking  in 
'i  very  hot  or  very  cold  day,  it  became  exceedingly  tense.  Ex- 
Lernally  it  covered  about  one-third  of  the  temporal  extremity  of  the 
'upper  eyelid,  and  it  occupied  the  whole  extent  of  the  lower  one. 
Ilhe  folds  of  which  were  separated  to  such  an  extent,  as  to  produce 
kn  unseemly,  irregular,  and  pendulous  swelling,  which  hung  down 
bver  the  cheek.  Towards  the  outer  canthus  of  the  eye,  the  morbid 
texture  was  interposed  between  the  conjunctiva  and  the  sclerotica, 
ito  within  the  eighth  of  an  inch  of  the  cornea.  It  was  chiefly  in 
this  direction  that  the  disease  was  spreading.  From  the  external 
'angle  of  the  eye  the  tumour  was  prolonged  both  outwards,  and 
'downwards.  In  the  first  direction  it  extended  to  the  point  of  junc- 
tion of  the  temporal  and  malar  bones;  in  the  latter,  it  descended 
'nearly  half  an  inch  below  the  line  of  the  parotid  duct.  Through 
its  whole  extent,  the  tumour  was  free  of  pulsation ;  no  large  artery 
bould  be  traced  into  it ;  by  pressure  it  was  readily  emptied  of  its 

*  Principles  of  Surgery,  Vol.  i.  p.  461.  Edin.  1801. 


132 


!l 


contents ;  but  slowly,  on  the  removal  of  the  pressure,  it  was  again 
filled.     When  emptied,  by  rubbing  the  collapsed  sac  between  the 
fingers,  a  doughy  impression  was  communicated  to  them.     On  the 
surface  it  was  of  a  dark  purple  colour,  with  a  tint  of  blue  on  those 
parts  covered  by  the  skin,  but  where  invested  by  the  conjunctiva, 
it  had  a  shade  of  red.     It  was  cold  and  flabby,  communicating  to 
the  fingers  the  same  sensation  which  is  received  on  grasping  the 
wattles  of  a  turkey  cock.     As  the  tumour  was  increasing,  and 
threatened  to  extend  over  the  eye,  the  patient  was  anxious  for  its 
removal.     Mr.  B.  began  the  operation  by  detaching  the  lower  eye- 
lid along  its  whole  extent,  he  then  dissected  away  that  part  of  the 
tumour  adhering  to  the  sclerotica,   and  next  removed  that  which 
adhered  to  the  upper  eyelid.     This  being  done,  he  tied  a  pretty 
large  artery  which  passed  into  the  tumour  from  the  outer  and  lower 
part  of  the  orbit,  by  the  temporal  side  of  the  inferior  oblique  muscle. 
The  next  stage  of  the  operation  consisted  is  dissecting  off  the  tu- 
mour from  the  aponeurosis  of  (he  temporal  muscle,  the  zygomatic 
process,  the  malar  bone,  and  from  over  the  branches  of  the  portio 
dura,  and  the  parotid  duct.     After  the  great  body  of  the  tumour 
was  in  this  way  removed,  Mr.  B.  found  that  still  a  part  of  the 
spongy  morbid  mass  remained  attached  to  the  parts  behind  the 
parotid  duct  and  portio  dura.     He  also  discovered  that  some  of  the 
tumour  dipt  beneath  the  fascia  of  the  temporal  muscle,  which  was 
reticulated.     From  these  parts  there  was  a  general  oozing  of  blood ; 
and  from  the  divided  transverse  fascial  artery,  as  well  as  from  the 
arteries  which  perforated  the  malar  bone  and  the  masseter  muscle, 
there  was  a  pretty  profuse  bleeding.     The  vessels  were  secured, 
and   then  with  the  forceps  and  scissors,  Mr.  B.  cleared  away  the 
diseased  matter  from  behind  the  parotid  duct  and  portio  dura,  both 
of  which  were  thus  detached  from  all  connexion  with   the  neigh- 
bouring parts.     In  the  same  way,  he  was  obliged  to  cut  away  a 
quantity  of  diseased  substance  from  behind  the  zygoma.     As  the 
morbid  parts  were  here  ill  defined,  and  much  intermixed  with  the 
fibres  of  the  temporal  muscle,  a  considerable  part  of  it  required  to 
be  taken  away,  and  in  doing  this,  the  deep-seated  anterior  temporal 
artery  was  divided.     What  of  the  tumour  remained  on  the  cheek, 
adhered  so  firmly  to  the  zygomatic  muscle,  and  was  so  closely  in- 
corporated with  its  substance,  that  the  one  could  not  be  separated 
from  the  other.     The  insulated   part  of  the  portio  dura  and  the 
parotid  duct  were  now  laid  back  on  the  masseter  muscle,  and  the 
edges  of  the  integuments  brought  into  contact  over  them,  and  sup- 
ported by  means  of  a  single  suture.     Over  the  malar  bone  the 
lips  of  the  wound  could  not  be  made  to  approach,   nor  did  the 
oozing  from  the  bone  cease.     A  fold  of  linen  and  a  layer  of  sponge 
were  therefore  laid  into  this  part  of  the  wound,  and  retained  there 
by  a  compress  and  bandage,  appHed  so  tightly,  as  to  restrain  the 
bleeding.     The  sponge  was  removed  two  days  afterwards,  and  an 
attempt  made  to  bring  the  lips  of  the  wound  nearer  to  each  other. 


133 

The  sore  soon  began  to  granulate,  and  threw  out  a  flabby  red  fun- 
gus, the  growth  of  which  could  not  be  checked  by  the  application 
.  of  sulphate  of  copper.     By  bringing  the  edges  of  the  sore  together, 
i  it  was  at  length   reduced  to  the  size  of  a  shilling,  and  was  soon 
j  afterwards  completely  cicatrized.     Three  years  after  the  operation, 
i  the  patient  continued  free  from  any  return  of  the  disease,  and  the 
■  cicatrice  was  becoming  smaller.     The  only  inconvenience  which 
i  he  experienced,  arose  from  the  motion  of  the  upper  eyelid  being 
1  impaired,  by  its  adhesion  to  that  part  of  the  sclerotica  Ifrom  which 
I  the  tumour  had  been  dissected.     From  the  same  cause,  the  eye 
'  did  not  possess  the  same  latitude  of  motion  as  formerly.     It  required 
!  a  considerable  effort  to  turn  the  pupil  toward  the  nose.* 
I      It  will  be  evident,  upon  the  slightest  consideration,  how  very 
different  in  activity,   if  not  in   nature,  this  case  of  Mr.   Burns  is 
from  that  of  Mr.  Bell,   and  how  much  less  the  danger  attending 
the  extirpation  of  such  a  passive  or  venous  aneurism  by  anasto- 
}  mosis,  compared  to  that  which  is  inseparable  from  every  atterapt  to 
touch  with  the  knife  the  active,  or  arterial  tumour  of  the  same  sort. 
I  The  terms  active  and  passive,   applied  to  this  disease,  cannot,  I 
I  think,  be  objected  to ;  but  probably  the  terms  arterial  and  venous 
I  may  be  incorrect.     We  are,  as  yet,  in   ignorance  of  the  real  struc- 
I  ture  of  aneurism  by  anastomosis,  and  therefore  cannot  pretend  to 
i  explain  its  varieties. 

;  The  bold  and  successful  practice  of  Mr.  Travers,  who,  for  an 
j  aneurism  by  anastomosis,  within  the  orbit,  tied  the  common  caro- 
I  tid  artery,  has  been  followed  by  Mr.  Wardrop  in  several  cases  of 
this  disease,  situated  externally.  In  these  cases,  Mr.  W.  went 
upon  the  probability,  that  if  the  current  of  blood  through  a  neevus 
were  arrested  by  tying  the  arterial  trunk  supplying  it,  the  blood 
contained  in  the  cells,  or  what  may  be  considered  as  the  parenchy- 
ma of  the  tumour,  would  be  put  at  rest,  and  undergo  a  process  of 
coagulation,  similar  to  the  blood  in  a  common  aneurismal  sac  after 
the  artery  has  been  tied  ;  and  likewise,  that  the  coagulated  blood 
would  be  afterwards  absorbed,  and  that  the  parenchyma  of  the 
tumour  would  gradually  shrink.  Mr.  Wardrop  has  pubhshed  the 
particulars  of  three  cases  of  nsevus  of  the  face,  in  which  he  tied 
the  common  carotid  artery.  All  the  three  patients  were  young 
children.  Two  of  them  died,  the  circumstances  previous  to  the 
operation  being  very  unfavourable.  The  successful  case  was  that 
of  a  female  child,  five  months  old,  who  had  a  large  subcutaneous 
nsevus  on  the  left  side  of  the  fac-e,  covering  one  half  of  the  root  of 
the  nose,  the  eyebrow,  and  the  upper  eyelid,  which  could  not  be 
sufficiently  opened  to  expose  the  eyeball,  nor  could  the  precise  lim- 
its of  the  disease  be  traced  in  the  orbit,  within  which  it  seemed  to 
penetrate  deeply.  The  tumour  was  of  a  pale  blue  colour,  and 
there  were  numerous  tortuous  veins  in  the  integuments  covering 

,  *  Observations  on  the  Surgical  Anatomy  of  the  Head  and  Neck,  p.  331.     Glas- 
gow, 1834. 


134 

it.  It  had  no  pulsation,  felt  doughy  and  inelastic,  and  when 
squeezed  could  be  greatly  diminished  ;  on  removal  of  the  pressure 
its  original  size  was  rapidly  restored.  As  it  would  have  been  ex- 
tremely dangerous,  and  probably  even  impracticable,  to  have  re- 
moved this  tumour  with  the  knife,  and  as  it  had  been  rapidly 
increasing  since  a  few  days  after  the  birth  of  the  child,  Mr.  W. 
concluded  that  the  only  chance  of  arresting  the  progress  of  the  dis- 
ease, was  by  tying  the  trunk  of  the  common  carotid  artery  of  that 
side  on  which  the  tumour  was  situated.  The  incision  of  the  in- 
teguments was  made  about  the  middle  of  the  neck,  along  the 
tracheal  edge  of  the  mastoid  muscle,  and  the  rest  of  the  dissection  was 
accomplished  chiefly  with  a  sharp-pointed  double-edged  silver  knife. 
The  operation  was  more  difficult  than  might  have  been  expected 
in  a  simple  dissection  amongst  healthy  parts,  from  the  unceasing 
crying  of  the  infant,  which  kept  the  larnyx  and  trachea  in  constant 
motion  upwards  and  downwards.  This  not  only  prevented  the 
pulsation  of  the  carotid  from  being  distinguished,  but  when  the 
sheath  of  the  vessel  was  distinctly  penetrated  by  the  point  of  the 
knife,  rendered  it  difficult  to  get  the  point  of  Bremner's  aneurismal 
needle  conducted  by  the  finger  fairly  within  the  sheath.  When, 
however,  the  latter  step  of  the  operation  was  accomphshed,  the 
needle  passed  around  the  artery  with  great  facility.  Some  divided 
vessels  bled  a  good  deal  during  the  operation,  so  that  the  wound 
was  kept  filled  with  blood,  and  the  dissection  was  necessarily  con- 
ducted with  the  finger  as  the  only  guide.  The  ligature  being  tied 
around  the  artery,  the  edges  of  the  wound  were  brought  together  by  a 
single  stitch,  and  no  adhesive  plaster  nor  bandage  employed.  The 
infant  appeared  pale  and  much  exhausted  after  the  operation,  and  had 
a  teaspoonful  of  the  syrup  of  white  poppies.  A  remarkable  change 
was  immediately  observed  in  the  tumour.  No  sooner  had  the  carotid 
been  tied,  than  the  child  was  observed  to  raise  the  upper  eyelid 
sufficiently  to  expose  the  eyeball,  which,  until  that  period,  had 
never  been  in  view,  on  account  of  the  swollen  state  of  the  hd.  The 
colour  of  the  tumour  also  changed,  losing  its  scarlet  hue,  and 
appearing  of  a  much  darker  blue  shade,  a  change,  observes  Mr.  W., 
which  evidently  had  arisen  from  the  collapse  of  the  arteries,  whilst 
the  veins  and  cells  of  the  tumour  remained  filled  with  venous  blood. 
Soon  after  the  operation  the  child  became  tranquil,  and  in  a  few 
hours  was  permitted  to  suck,  care  having  been  taken  to  keep  the 
mother's  mind  tranquil,  by  her  absence  during  the  operation,  and  by 
concealing  from  her  the  extent  of  the  wound.  The  child  passed  u 
very  quiet  night,  the  operation  seeming  to  produce  very  slight 
excitement  in  the  general  system.  She  continued  to  suck  as  if 
nothing  had  happened,  and  the  wound  inflamed  so  little  as  to  re- 
quire no  dressing.  The  ligature  came  away  upon  the  eleventh 
day.  On  the  day  following  the  operation,  the  tumour  continued  of 
the  same  diminished  bulk,  and  of  the  same  dark  purple  colour, 
which  it  had  assumed  immediately  after  the  artery  was  tied,  and 


135 

^  on  feeling  it,  it  seemed  either  as  if  the  blood  which  it  contained  had 
coagulated,  or  that  it  was  emptied  of  its  blood  ;  for  pressure,  instead 
of  emptying  its  contents,  now  made  no  sensible  alteration  in  its  size. 
A  gradual,  though  not  always  regularly  progressive  diminution 
followed  ;  by  degrees,  more  and  more  of  the  eyeball  became  ex- 
posed ;  and  ten  months  after  the  operation,  nothing  of  the  tumour 
remained,  more  than  the  membranous  bag  which  was  originally 
distended  with  blood.* 


SECTION    XVI. NEURALGIA,    OR    TIC    DOULOUREUX. 

The  branches  of  the  first  and  second  divisions  of  the  fifth  pair  of 
nerves,  distributed  to  the  eye,  eyeUds,  and  circum -orbital  region,  are 
more  frequently  the  seats  of  severe  pain  than  any  other  nerves  of 
the  body.  We  meet,  in  the  first  place,  with  cases,  in  which  these 
nerves  are  affected  with  paroxysms  of  pain,  without  any  other 
signs  of  disease  being  present.  In  the  second  place,  these  nerves 
are  affected  with  pain,  while,  at  the  same  time,  the  sclerotica  and 
iris  are  inflamed.  In  a  third  set  of  cases,  the  teeth  are  decayed, 
often  the  vitreous  humour  glaucomatous,  and  vision  impaired.  In 
a  fourth  set,  there  are  attendant  on  the  pain,  unequivocal  signs  of 
organic  disease  within  the  cranium.  To  the  first  and  fourth  of 
these  sets  of  cases,  the  names  neuralgia  and  tic  douloureux  are 
generally  appUed.  The  second  and  third  sets  are  accounted  rheu- 
matic. 

i^ymptoms.  In  the  commencement  of  neuralgia,  the  pain 
occurs  only  momentarily,  and  perhaps  not  oftener  than  once  or 
twice  in  twenty-four  hours.  The  upper  eyelid,  the  middle  of  the 
eyebrow,  and  the  temple,  are  its  most  frequent  seats.  The  side  of 
the  nose,  the  lower  lid,  and  the  cheek,  are  less  commonly  affected 
in  incipient  cases.  As  the  disease  proceeds,  the  pain  becomes  more 
violent,  but  still  continues  only  for  an  instant.  Gradually  its  attacks 
are  more  frequently  repeated,  last  longer,  although  rarely  above  half  a 
minute,  and  attain  a  degree  of  most  overpowering  severity.  The  pain 
is  almost  always  referred  to  one  spot ;  it  appears  to  be  situated  in  one 
or  other  of  the  large  branches  of  the  fifth  pair  ;  if  it  spreads,  it  does 
so  in  the  direction  of  the  ramifications  of  the  nerves.  In  advanced 
cases,  we  observe,  that  during  a  paroxysm,  the  eyebrows  are  knit, 
the  lids  firmly  closed,  the  angle  of  the  mouth  drawn  towards  the 
ear,  the  lower  jaw  fixed,  and  respiration  as  much  as  possible  sup- 
pressed. The  muscles  in  the  immediate  vicinity  of  the  pain  are 
sometimes  affected  with  a  degree  of  quivering,  tremor,  or  slight 
convulsion  ;  but  this  is  not  an  invariable  symptom,  and  when  it 
does  occur,  seems  to  be  merely  an  effect  of  the  violence  of  the  pain. 
The  pain  is  not  equally  violent  during  the  whole  time  of  an  attack. 

*  Lancet,  Vol.  xii.  p.  267.  London,  1827.  Mr.  Wardrop's  unsuccessful  cases 
are  contained  in  the  Medico-Chirurgical  Transactions,  Vol.  ix.,  and  in  the  volume  of 
the  Lancet  now  quoted. 


136 

In  general,  it  increases  by  degrees,  and  is  most  severe  a  short  time 
before  it  ceases,  which  it  commonly  does  with  equal  suddeness  as 
it  makes  its  attack.  This  disease  is  completely  intermittent. 
Whenever  the  fit  is  over,  the  patient  feels  peifectly  free  from  un- 
easiness in  the  part,  which  but  an  instant  iDcfore  was  the  seat  of 
excruciating  pain. 

The  symptoms  occasionally  attendant  on  neuralgia  of  the  fifth 
pair,  and  indicative  of  serious  organic  changes  within  the  cranium, 
are  amaurosis,  palsy  of  the  muscles  of  the  eyeball,  and  of  the  leva- 
tor palpebrae  superioris.  inflammation  of  the  cornea,  ending  in  ulcer- 
ation, and  deformity  of  the  hones  forming  the  back  and  roof  of  the 
throat.  The  inflammation  and  other  changes  of  the  eye  in  such 
cases  resemble  very  much  the  effects  produced  in  Majendie's  experi- 
ment of  dividing  the  trunk  of  the  fifth  pair. 

CoyistitufAonal  Symptoms.  It  is  only  in  confirmed  cases  that 
any  symptoms  of  this  kind  are  present.  When  the  disease  has 
continued  for  a  length  of  time  without  amelioration,  and  the  attacks 
are  very  frequent,  the  patient  becomes  restless  and  melanchol3^  in- 
sensible to  the  pleasures  of  society,  and  incapable  of  occupation, 
the  appetite  for  food  fails,  digestion  is  impaired,  the  bowels  become 
bound,  the  body  becomes  emaciated,  the  sexual  passion  is  extin- 
guished, and  the  patient  is  almost  totally  deprived  of  sleep. 

Subjects.  No  age  is  exempt  from  this  disease.  Men  are  more 
frequently  affected  wnth  it  than  women.  It  is  by  no  means  the 
nervous  or  hypochondriac  that  are  most  exposed  to  it. 

Causes.  In  many  cases,  this  disease  appears  to  arise  from 
causes  similar  to  those  which  induce  rheumatic  opthalmia,  and  es- 
pecially continued  exposure  to  draughts  of  cold  air.  While  causes 
of  this  sort  give  origin  to  the  first  attacks,  we  observe  a  variety  of 
occasional  circumstances  which  operate  in  re-inducing  the  parox- 
ysms, as  the  motions  of  the  face  in  speaking,  chewing,  or  swallow- 
ing, simple  touching  of  the  part,  the  shocks  which  the  body  is  apt 
to  undergo  in  walking  or  riding,  the  blov\-ing  of  the  wind  over  the 
face,  the  sudden  opening  or  shutting  of  a  door,  and  many  others. 

The  paroxysms  are  much  more  frequent  during  the  day,  on  ac- 
count of  the  presence  of  many  more  exciting  causes,  than  during 
the  night.  The  complaint  is  much  aggravated  during  the  preva- 
lence of  easterlv  and  north-easterly  winds. 

We  are  iniable  to  say  any  thing  certain  regarding  the  proximate 
cause  of  simple  neuralgia.  When  there  are  paralytic  symptoms 
along  with  neuralgia,  it  is  probable  that  pressure  on  the  third  and 
fifth  pairs  exists  within  the  cranium,  from  thickening  of  the  dura 
mater,  spiculee  of  bone,  or  the  hke. 

Treatment.  1.  We  are  highly  indebted  to  Mr.  Hutchinson,  of 
Southwell,  for  the  introduction  of  the  precipitated  carbonate  of  iron, 
as  a  remedy  in  neuralgia.  I  have  used  it  in  a  variety  of  cases, 
both  simple  and  complicated.  In  the  former  it  has  always  proved 
successful.     In  painful  affections  of  the  circum-orbital  region,  ac- 


137 

conipanying  glaucoma  and  amaurosis,  I  have  also  found  it  highly 
serviceable.  In  cases  apparently  connected  with  serious  organic 
changes  within  the  cranium,  it  has  not  appeared  to  be  productive  of 
any  effect.  The  dose  of  the  carbonate  of  iron  may  be  from  fifteen 
grains  to  a  drachm  twice  or  thrice  a-day.  Mr.  H.  appears  to  give 
a  drachm  as  his  usual  dose  ;  but  I  have  found  it  effectual  in  much 
smaller  quantities.  Should  the  medicine  produce  no  relief  in  small 
doses,  it  ought  to  be  tried  in  larger  quantity.  Mr.  H.  mentions  a 
case  in  which  half  a  drachm  three  times  a-day,  produced  little  per- 
ceptible benefit;  he  increased  the  dose  to  a  drachm  twice  a-day, 
Avhen,  after  three  days,  a  very  sensible  abatement  of  the  number 
and  violence  of  the  paroxysms  was  observed ;  he  again  increased 
the  dose  to  four  scruples  twice  a-day,  in  which  the  patient  persevered 
regularly  for  ten  weeks,  at  the  expiration  of  which  time,  not  the 
slightest  vestige  of  the  disease  remained.  He  gives  several  other 
cases,  in  which  little  or  no  effect  was  produced  by  smaller  doses 
than  four  scruples  twice  a-day.  Mr.  H.'s  pamphlet  is  well  worthy 
of  perusal.* 

2.  Another  remedy  of  great  utihty  in  the  treatment  of  this  dis- 
ease is  belladonna,  for  the  suggestion  of  which  we  are  indebted  to 
Mr.  Bailey,  of  Harwich.  It  is  a  medicine  of  so  much  activity,  that 
it  must  be  given  with  a  very  cautious  hand.  The  form  which  I 
have  adopted  for  internal,  and  sometimes  also  for  external  use,  is  a 
vinous  tincture  of  the  extract,  prepared  by  macerating,  for  four  days, 
one  drachm  of  the  extract  in  one  pint  of  white  wine.  Of  this,  as  a 
dose,  I  begin  with  five  drops  thrice  a-day,  increasing  gradually  to 
15  drops.  Besides  soothing,  and  in  many  cases,  removing  entirely 
the  neuralgia,  the  use  of  this  medicine  induces  a  very  peculiar  sense 
of  thirst  and  constriction  in  the  throat ;  and  in  larger  doses,  brings 
on  cramp  of  the  stomach,  dilatation  of  the  pupils,  temporary  blind- 
ness, vertigo,  and  a  highly  distressing  feeling  of  weakness  and 
sinking.  The  cases  related  by  Mr.  B.  are  extremely  interesting-.f 
He  ventures  on  2  or  even  3  grains  of  the  extract  at  once,  and  ap- 
pears to  have  been  led  to  this  mode  of  exhibiting  the  medicine  from 
the  difficulty  of  getting  the  patients  to  continue  smaller  doses  for 
any  length  of  time,  in  consequence  of  its  unpleasant  effects,  while 
many  were  completely  and  permanently  relieved  by  a  single  large 
dose.  I  have  found  belladonna  useful  in  almost  every  variety  of 
neuralgia  ;  but  of  late  I  have  prescribed  it  less  frequently,  in  con- 
sequence of  making  use  of  the  carbonate  of  iron. 

3.  Calomel  and  opium  have  been  recommended  for  neuralgia, 
and  occasionally  prove  useful ;  although,  in  many  instances,  any 
degree  of  affection  of  the  mouth  in  this  complaint,  is  found  to  ag- 
gravate the  symptoms.     In  a  case  of  neuralgia,  attended  with  ul- 

'^  Cases  of  Neuralgia  Spasmodica,  commonly  called  Tic  Douloureux,  successfully 
treated.     London,  1822. 

t  Observations  relative  to  the  Use  of  Belladonna  in  Painful  Disorders  of  the  Head 
and  Face.    London,  1818. 

18 


138 

cerated  cornea,  arising  without  any  active  inflammation,  and  ap- 
parently merely  as  a  consequence  of  the  diseased  state  of  the  fifth 
pair  of  nerves,  I  found  calomel  and  opium  internally,  and  the  lunar 
caustic  solution  externally,  successful  in  procuring  the  cicatrization 
of  the  ulcer. 

4.  Arsenic  has  often  been  tried  in  this  disease,  but  appears  to 
have  little  or  no  effect. 

5.  The  division  of  the  afiected  nerve  is  also  laid  aside. 

6.  Plasters  worn  over  the  seat  of  the  pain  sometimes  serve  to 
moderate  it.  They  are  made  with  opium,  cicuta,  belladonna,  and 
other  narcotics. 


SECTION  XVII. TWITCHING  OR  QUIVERING  OF    THE  EYELIDS. 

I  have  often  been  consulted  by  patients  who  complained  of  a 
tremulous,  quivering,  or  twitching  motion  of  one  or  other  eyelid,  or 
of  both,  which  they  w^ere  unable  to  control  or  to  prevent,  and 
which,  from  the  frequency  of  its  repetition,  had  become  very  an- 
noying, although  not  attended  with  any  pain.  This,  I  believe,  is 
the  complaint  called  by  the  French  ticnon-douloureux.  In  many 
cases  of  this  disease,  the  quivering  of  the  orbicularis  palpebrarum  is 
so  shght,  as  not  to  produce  any  visible  motion  of  the  affected  lid  ; 
but  in  other  cases,  the  motion  is  very  evident,  and  is  not  confined 
to  the  lids,  but  extends  to  other  muscles  of  the  face,  and  especially 
to  the  zygomatici,  so  that  w^hile  the  hds  are  affected  wath  an  oscil- 
latory or  wiuking  motion,  the  angle  of  the  mouth  is  drawni  up- 
w^ards.  Agitation  of  mind  generally  aggravates  this  convulsive 
state  of  the  face,  so  that  in  speaking  to  a  stranger,  it  becomes  much 
increased.  The  patient  is  conscious  of  this,  his  feehngs  are  hurt 
by  the  knowledge  of  his  being  subject  to  the  complaint,  and  he 
becomes  anxious  to  undergo  any  sort  of  treatment  likely  to  reheve 
him,  not  excepting  an  operation.  Although  in  by  far  the  greater 
number  of  cases,  no  pain  attends  this  disease,  it  is  occasionally  ac- 
companied by  pain  so  severe,  as  to  resemble  the  tic  douloureux.  1 
have  uniformly  found  the  digestive  organs  deranged  in  the  subjects 
of  this  disease. 

The  physiological  discoveries  of  Mr.  Charles  Bell  regarding  the 
offices  of  the  fifth  pair,  and  portio  dura  of  the  seventh  pair,  lead  us 
to  refer  the  diseased  motions  of  the  face,  as  well  as  all  its  healthy 
motions,  both  voluntary  and  involuntary,  to  the  influence  of  the 
latter  nerve. 

Treatment.  1.  The  most  essential  part  of  the  treatment  con- 
sists in  the  use  of  alterative,  laxative,  and  tonic  medicines.  A  blue 
pill  every  night,  or  every  second  night,  and  one  or  two  compound 
rhubarb  pills  every  morning,  for  a  fortnight,  will  generally  be  at- 
tended with  much  benefit ;  after  which  a  course  of  bitter  infiision, 
cinchona,  or  carbonate  of  iron,  ought  to  be  prescribed,  along  with 
country  air  and  exercise. 


I- 


139 


2.  Anodyne  liniments  rubbed  in  the  course  of  the  portio  dura 
tiave  been  recommended. 

3.  Pressure,  so  as  to  hmit  the  motion  of  the  parts  spasmodically 
;  affected,  has  been  found  advantageous,  tending  to  break  the  habit, 
3n  which,  in  a  great  measure,  the  complaint  depends,  however  it 
may  have  been  originally  produced. 


SECTION  XVIII.— -MORBID  NICTITATION. 

Natural  nictitation  appears  to  be  performed  chiefly  by  the  alter- 
nate relaxation  and  contraction  of  the  levator  palpebrse  superioris, 
and  is  accomplished  so  instantaneously  and  easily  as  scarcely  to  at- 
tract the  attention  of  ourselves  or  others  ;  but  there  is  a  morbid 
nictitation,  which  appears  to  be  more  a  convulsive  action  of  the  or- 
'bicularis  palpebrarum,  too  remarkable  not  to  be  observed  by  others, 
'and  of  which,  at  last,  the  patient  himself  becomes  conscious.  In 
some  cases  it  seems  to  affect  the  upper ;  and  in  other  cases,  more 
the  lower  lid.  Sometimes  one  eye  only  ;  at  other  times  both  eyes 
are  affected.  Although  different  from  the  subject  of  the  last  section, 
the  present  disease  is  aggravated  by  the  same  causes  which  aggra- 
vate the  former,  especially  by  agitation  of  mind,  and  disordered  di- 
gestion. 

Sometimes  a  single  eyelash,  growing  inwards,  so  as  to  touch  the 
eyeball,  is  the  cause  of  morbid  nictitation.  In  other  instances,  slight 
ophthalmia  produces  it.  These  causes  being  removed,  the  com- 
plaint w^ill  cease.  In  all  other  cases,  a  treatment  similar  to  what 
has  been  recommended  for  quivering  of  the  eyelids,  must  be 
adopted. 


SECTION    XIX. PHOTOPHOBIA,    AND    SPASM    OF    THE    EYELIDS. 

Intolerance  of  light,  and  spasmodic  contraction  of  the  orbicularis 
palpebiarum,  almost  always  go  together,  as  effects  produced  by  the 
same  cause,  so  that  we  rarely  observe  any  thing  like  a  pure  blepha- 
ro-spasmus.  The  common  causes  of  photophobia,  and  spasm  of  the 
lids,  are,  a  particle  of  dust  in  one  or  other  of  the  folds  of  the  conjunc- 
tiva, an  inverted  eyelash,  or  strumous  conjunctivitis.  In  the  last 
instance,  the  spasm  is  often  continued  for  weeks  together,  the  pa- 
tient being  unable  all  that  time  to  bear  the  least  accession  of  light, 
or  to  open  the  eyes  in  the  smallest  degree.  The  inflammation  dur- 
ing all  this  time  may  be  very  inconsiderable,  so  that  on  forcing 
open  the  lids,  scarcel}'"  a  red  vessel  is  discovered.  Such,  however, 
is  the  sympathy  between  the  conjunctiva,  which  is  the  seat 
of  the  disease,  and  the  neighbouring  parts,  that  the  admitted  light 
seems  to  the  patient  to  blaze  like  the  rays  of  the  sun  reflected  from 
a  mirror,  the  lachrymal  gland  instantly  pours  out  a  tide  of  burning 
tears,  and  the  spasm  of  the  orbicularis  palpebrarum  forces  the  lids 


140 

together  with  new  violence.  The  photophobia,  and  spasm  of  the 
eyelids,  depending  on  the  causes  aheady  mentioned,  generally  sub- 
side very  soon  after  the  foreign  particle  is  removed,  or  the  ophthal- 
mia subdued. 

As  for  cases  of  pure  blepharo-spasmus,  I  have  seen  but  very  few. 
In  some  patients,  however,  we  find  morbid  nictitation  go  to  such  a 
degree,  that  the  lids  cannot  be  opened  for  several  seconds,  during 
which  period,  the  eyeball  is  strongly  pressed  by  the  contraction  of 
the  orbicularis.  The  venerable  Blumenbach  is  subject  to  an  affec- 
tion of  this  sort,  so  that  during  conversation,  or  at  lecture,  he  em- 
ploys his  finger  to  overcome  the  closed  state  of  the  lids. 

In  other  cases,  spasm  of  the  orbicularis  of  one  side  is  brought  on 
in  consequence  of  a  blow  on  the  head,  or  other  injury,  the  effects  of 
which  have  been  communicated  to  the  brain  or  its  membranes. 
The  spasm  continues  long,  for  weeks,  perhaps,  or  months,  and  is 
apt  to  be  mistaken  for  palsy  of  the  levator  of  the  upper  lid.  A  rest- 
less state  of  the  edge  of  the  upper  lid,  and  the  difficulty  experienced 
in  raising  the  lid  even  wdth  the  finger,  will  serve  to  distinguish  this 
state  from  palsy. 

The  treatment  of  pure  blepharo-spasmus  will  consist  in  laxatives, 
tonics,  and  antispasmodics,  internally,  and  in  counter-irritation  ex- 
ternally. This  is  to  be  accomplished  by  friction  with  volatile  lini- 
ment, tincture  of  cantharides,  and  the  like,  on  the  forehead  and 
temple,  and  behind  and  before  the  ear,  the  apphcation  of  blisters, 
and  the  insertion  of  issues.  Fomentations  with  poppy,  or  chamo- 
mile decoction  are  useful.  Poultices,  containing  opium,  hyoscya- 
mus,  or  cicuta,  are  also  recommended  to  be  applied  over  the  eye. 
In  cases  where  the  spasm  is  traced  to  injury  of  the  head,  blood-let- 
ting from  the  arm,  leeches  to  the  head,  and  a  course  of  mercury, 
will  be  required. 

Benedict  has  treated  of  the  intolerance  of  light  which  attends 
strumous  ophthalmia,  as  a  separate  disease,  under  the  name  of  pho- 
tophobia infantimi  scrophulosa.  He  recommends  chiefly  small 
doses  of  calomel,  and  the  warm  bath.* 


SECTION    XX. PALSY    OF    THE     ORBICULARIS     PALPEBRARUM. 

In  many  cases  of  partial  palsy  of  the  face,  there  is  a  degree  of 
lagophthalmos  present,  or  in  other  words,  the  eyelids  cannot  be 
completely  closed,  on  account  of  paralysis  of  the  orbicularis  palpe- 
brarum. The  patient  cannot  elevate  his  eyebrow,  nor  frown  ;  he 
cannot  wink  hard,  nor  press  the  eyelids  against  the  eyeball.  The 
tears  run  over  on  the  cheek,  from  want  of  the  action  of  the  lower 
Md,  which  hangs  depressed  and  everted ;  exposed  to  dust  flying 
about,  the  patient  is  distressed  by  its  getting  into  his  eye  ;  and  thus 
inflammation  and  opacity  of  the  cornea  may  be  excited.     The 

•  Beitrage  ftlr  practische  Medizin  und  Ophthalmiatrik.  Vol.  i.  p.  3.  Leipzig,  1812. 


141 

other  muscles  of  the  face  are  at  the  same  time  paralyzed.  The 
sensation  of  touch  is  perfect,  depending  on  the  fifth  pair ;  but  the 
motion  of  the  lips  is  lost  on  the  paralyzed  side^  the  mouth  is 
dragged  from  the  palsied  towards  the  sound  side ;  and  even  the 
nose  is  twisted.  From  the  exposed  state  of  the  eye,  the  patient 
has  a  feehng  of  cold  in  it,  which  he  remedies  by  covering  the  eye, 
perhaps,  with  his  hand.  Occasionally  he  complains  of  pain  at  the 
root  of  the  ear,  or  in  the  neighbourhood  of  the  stylo-mastoid  fora- 
men, from  which  the  portio  dura  escapes,  to  send  its  branches  over 
the  face.  Pain  is  sometimes  felt,  at  the  commencement  of  the 
disease,  radiating  along  the  branches  of  the  nerve. 

Causes.  Exposure  to  a  current  of  cold  air,  producing  inflamma- 
tion of  the  portio  dura,  and,  perhaps,  in  some  cases,  inflammatory 
sweUing  and  diminution  of  the  caliber  of  the  Fallopian  aqueduct, 
so  as  to  press  on  the  Uunk  of  the  nerve,  is  the  most  frequent  cause 
of  partial  palsy  of  the  face.  It  has  been  known  to  arise  from  the 
pressure  of  a  lymphatic  gland  between  the  mastoid  process  and  the 
angle  of  the  jaw^  owing  to  inflammation  of  the  mouth  from  the 
action  of  mercury.  An  abscess  of  the  tympanum,  affecting  the 
Fallopian  aqueduct,  may  produce  it ;  or  a  division  of  the  portio 
dura  in  any  surgical  operation  about  the  angle  of  the  jaw.  One 
or  other  branch  of  the  nerve  may  in  this  way  be  divided,  and  con- 
sequently one  or  other  hd  only  be  palsied.  Care  must  be  taken 
lest  the  affection  be  erroneously  supposed  to  arise  from  disease 
within  the  cranium. 

Treatment.  This  must  be  directed  neither  against  the  brain 
nor  against  the  eyelids,  but  against  the  portio  dura.  Antiphlogistic 
means  of  cure  are  to  be  adopted  in  the  first  instance,  as  leeches 
behind  the  ear  and  near  the  angle  of  the  jaw,  cupping  on  the  back 
of  the  neck,  and  free  purging.  Calomel  and  opium,  and  the  use 
of  diaphoretics,  may  next  be  had  recourse  to.  A  semilunar  blister 
round  the  ear,  and  stimulating  liniments  to  the  paralyzed  parts, 
will  be  found  of  advantage.  Should  these  means  not  prove  effec- 
tual, a  trial  may  be  given  to  electricity. 


SECTION     XXI. — PTOSIS,    OR     PALLING     DOWN   OF    THE    UPPER 

EYELID. 

Inability  to  raise  the  uppei-  eyelid  may  either  depend  on  a  me- 
:  -chanical  cause,  or  arise  from  weakness,  or  be  paralytic. 

1.  Mechanical. 

After  inflammation  of  the  upper  eyelid,  attended  with  consider- 
able (Edematous  or  sanguineous  effusion  into  its  substance,  or  treated 
by  the  long-continued  use  of  cataplasms,  we  not  unfrequently  find 
the  integuments  so  much  relaxed,  that  they  form  a  fold,  hanging 
down  over  the  opening  of  the  lids,  while  the  levator  palpebrse 


142 

superioris  is  unable,  from  the  weight  and  bulk  of  the  Ud,  to  raise 
it  so  as  to  uncover  the  eye.  We  perceive  distinctly  the  endeavours 
of  the  muscle,  as  soon  as  the  patient  is  earnestly  desirous  of  opening 
his  eye,  but  the  eyelid  is  either  raised  only  to  a  very  inconsiderable 
degree,  or  remains  completely  prolapsed.  If  we  take  hold,  between 
the  finger  and  thumb,  of  the  relaxed  fold  of  skin,  so  as  to  relieve 
the  levator  muscle  of  the  additional  weight  of  this  superfluous  por- 
tion of  integuments,  the  patient  can,  without  diflficulty,  open  his 
eye ;  but  as  soon  as  we  quit  our  hold,  the  eyelid  descends  gradually 
to  its  former  position.  Sometimes  the  relaxation  does  not  occupy 
so  much  the  middle  of  the  eyelid  as  its  temporal  portion.  It  is  also 
occasionally  the  case,  that  when  the  fold  of  integuments  is  very 
considerable,  it  presses,  by  its  weight,  the  edge  of  the  lid,  along 
with  its  cilia,  inwards,  so  as  to  produce  a  degree  of  entropium. 

For  the  cure  of  this  variety  of  ptosis,  the  common  practice  is  to 
remove  a  transverse  fold  of  the  integuments  of  the  affected  hd. 
In  order  to  perform  this  with  the  necessary  exactness,  with  a  broad 
convex-edged  pair  of  forceps,  we  take  hold  of  the  skin,  where  it 
appears  most  relaxed,  and  then  desire  the  patient  repeatedly  to 
open  and  shut  the  e3'^e.  If  he  be  able  to  do  this,  it  is  a  proof  that 
the  forceps  include  neither  too  much  nor  too  little  of  the  skin.  If 
he  cannot  lift  the  lid,  we  have  taken  hold  of  too  little,  and  must 
apply  the  forceps  again,  so  as  to  include  a  greater  portion  of  skin. 
If  he  can,  indeed,  lift  the  lid,  but  not  completely  shut  it  again,  we 
must  let  go  a  little  of  the  skin  from  the  grasp  of  the  instrument. 
It  is  important  also  to  take  care  that  we  do  not  apply  the  blade  of 
the  forceps  too  close  to  the  edge  of  the  lid,  for  if  this  be  done,  too 
little  space  will  be  left  for  the  application  of  stitches.  As  soon, 
then,  as  the  forceps  are  properly  applied,  we  squeeze  their  blades 
together  with  moderate  firmness,  that  the  integuments  may  not 
escape,  and  then  remove  the  portion  laid  hold  of,  by  a  single  stroke 
of  the  scissors.  The  bleeding  is  inconsiderable,  and  ceases  in  a 
few  minutes  by  the  use  of  cold  water.  Never  more  than  two 
stitches  are  necessary  ;  one  is  frequently  suflScient.  Union  is  gen- 
erally effected  without  any  suppuration,  and  as  soon  as  the  union 
is  complete,  the  prolapsus  is  cured. 

2.  Atonic. 

In  some  instances,  we  meet  with  a  depressed  state  of  the  upper 
eyehd,  dependent  apparently  on  mere  w^eakness  of  the  levator 
muscle. 

In  this  case,  mechanical  support,  by  means  of  a  strip  of  adhe- 
sive plaster,  assists  in  restoring  to  the  muscle  its  wonted  power- 
Applications  of  a  strengthening  kind  are  to  be  made  to  the  lids,  as 
bathing  with  rose-water,  friction  with  tinctura  saponis,  and  the 
like.     Electricity  may  also  be  tried,  and  general  tonics. 


143 

3.  Paralytic. 

Palsy  of  the  levator  palpebrse  supeiioris  is  exceedingly  unlikely 
to  arise  from  a  division  of  the  branch  of  the  motor  oculi,  which 
supplies  that  muscle  with  nervous  energy  ;  for  that  branch  lies 
deep  in  the  orbit,  enters  the  muscle  by  its  inferior  side,  and  is 
therefore  not  likely  to  be  touched,  except  in  a  wound  penetrating 
so  much  into  the  orbit,  as  to  implicate  other  parts.* 

Palsy  of  the  levator  of  the  upper  lid  is,  however,  an  affection  by 
no  means  uncommon.  In  one  set  of  cases,  it  bears  an  analogy  in 
point  of  cause  to  the  partial  palsy  of  the  face  already  spoken  of,  or, 
in  other  words,  it  arises  from  cold,  and  is  part  of  a  rheumatic 
palsy  of  the  eye.  In  another  set  of  cases,  the  cause  is  cerebral ; 
it  is  serous  effusion,  or  some  tumour,  formed  within  the  cranium, 
and  pressing  on  the  third  pair  of  nerves.  It  is  often  difficult,  es- 
pecially in  the  incipient  stage,  to  distinguish  these  two  sets  of 
cases. 

In  both,  we  generally  find  either  all  the  muscles  of  the  eyeball 
also  paralyzed,  so  that  the  eye  stands  stock-still  in  the  orbit,  or  the 
abductor  retains  its  power,  so  that  the  eye  is  turned  towards  the 
temple,  while  the  other  recti  being  paralyzed,  the  patient  is  unable  to 
move  his  e3'e  upwards,  downwards,  or  inwards.  In  rheumatic  cases, 
one  side  only  is  generally  affected,  and  the  abductor  retains  its  power. 
In  cerebral  cases,  both  eyes  are  more  apt  to  be  affected  from  the 
beginning,  although  sometimes  one  side  is  first  paralyzed  and  then 
the  other. 

The  effect  of  palsy  of  the  levator  palpebrse  superioris,  is,  of 
course,  to  deprive  the  patient  of  sight.  He  sees  none,  unless  he 
raises  the  lid  with  his  finger.  When  he  does  so,  he  generally  sees 
double,  and  if  he  tries  to  walk  across  the  room,  he  is  affected  with 
a  great  degree  of  vertigo.  The  double-vision,  and  the  vertigo, 
cease  as  soon  as  the  lid  is  allowed  to  drop,  and  are  to  be  attributed 
to  the  misplaced  state  of  the  eyeball,  which  generally  attends  this 
paralysis  of  the  upper  lid. 

The  rheumatic  variety  of  this  palsy  is  brought  on  by  exposure  to 
currents  of  cold  air.  The  cerebral  is  either  sudden,  or  slow ;  the 
sudden  arising  after  fatiguing  exertion,  exposure  to  the  direct  rays 
of  the  sun,  intoxication,  blows  on  the  head,  and  the  like  ;  the  slow 
keeping  pace  with  the  growth  of  scrofulous  tumours,  fungous 
growths  from  the  dura  mater,  and  other  organic  changes  at  the 
basis  of  the  skull. 

Treatment.  Both  in  the  rheumatic  and  in  the  sudden  cerebral 
palsy  of  the  upper  lid,  we  employ  blood-letting,  general  and  local, 
rest,  the  antiphlogistic  regimen,  and  blistering  of  the  head.  After 
the  use  of  these  means,  we  generally  find  the  vertigo  to  be  re- 
moved, and  gradually  the  other  symptoms  begin  to  yield.  In  both 
cases,  we  employ  mercury  till  the  mouth  is  affected,  combining  it 

*  Seepage  101. 


144 

in  rheumatic  cases  with  opium,  as  a  sudorific,  and  in  cerebral  eases 
expecting  it  to  prove  useful  as  a  sorbefacient.  Sudorifics,  as  gnaiac, 
and  stimulants,  as  camphor,  have  been  highly  recommended  in  the 
rheumatic  cases.  Issues  in  the  neck,  and  behind  the  angle  of  the 
jaw,  and  the  use  of  electricity,  have  been  attended  with  advan- 
tage. In  slow  cerebral  cases,  I  have  seen  almost  every  sort  of 
practice  tried  without  effect. 

Some  cases  of  ptosis  are  congenital.  I  am  unable  to  say 
whether  they  are  paralytic,  or  arise  from  some  defect  in  the  struc- 
ture of  the  levator  muscle.  They  sometimes  appear,  for  a  time, 
to  be  bettered  by  the  operation  already  described,  for  ptosis  arising 
from  mechanical  causes  ;  but  the  relief  is  only  temporar)^,  for  the 
lid  soon  returns  to  its  former  depressed  and  motionless  state. 


SECTION    XXII. LAGOPHTHALMOS,    AND    RETRACTION    OP    THE 

EYELIDS. 

The  term  lagophthalmos  is  employed  to  denote  that  state,  in 
which  the  eyelids  cannot  l^e  completely  closed,  so  that  even  during 
sleep,  a  part  of  the  surface  of  the  eyetell  remains  exposed  to  the 
action  of  the  air,  and  the  irritation,  of  foreign  particles.  This  state 
is  generally  the  result  of  shortening  of  the  upper  eyelid,  from  the 
contraction  attending  the  cicatrization  of  a  burn  or  other  injury,  or 
of  the  retraction  of  that  lid  arising  from  caries  of  the  roof  of  the  or- 
bit ;  and  in  either  case,  lagophthalmos  may  or  may  not  be  attended 
with  eversion  of  the  affected  lid. 

I  have  been  consulted  on  account  of  a  great  degree  of  retraction 
or  depression  of  the  lower  lid,  consequent  neither  to  destruction  of 
its  integuments,  nor  disease  of  the  bone.  I  was  led  to  suspect  that 
suppuration  between  the  eyeball  and  the  floor  of  the  orbit,  had  been 
the  cause  of  this  diseased  position  of  the  lid,  but  nothing  of  this 
kind  appeared  from  the  history  of  the  case  to  have  happened. 

Another  variety  of  lagophthalmos  is  the  result  of  palsy  of  the 
orbicularis  palpebrarum,  which  allows  the  lower  eyelid  to  drop,  and 
prevents  it  even  during  the  strongest  act  bi  volition  from  meeting" 
exactly  with  the  upper. 

A  slight  degree  of  lagophthalmos  may  not  be  attended  b}"  almost 
any  bad  consequences.  When  more  considerable,  inflammation  of 
the  conjunctiva  and  cornea,  opacity  of  the  cornea,  and  even  staphy- 
loma, may  be  the  results.  The  exposed  eye  is  incapable  of  the 
usual  exertion,  and  is  affected  with  epiphora  and  intolerance  of 
hght. 

Of  the  lagophthalmos  from  palsy,  nothing  farther  reqtdres  to  be 
said.  The  ancients  attempted  to  reUeve  this  state  of  the  eyehds^ 
w^hen  it  arose  from  a  cicatrice,  by  a  transverse  incision  through  the 
contracted  integuments,  separating  the  edges  of  the  incision  as  much 
as  possible,  and  endeavouring  to  keep  them  separate  by  the  inter- 


145 

position  of  dressings,  till  the  cure  was  complete.  This  plan  was 
found  to  be  ineffectual ;  as  the  cicatrice,  arising  from  the  operation 
itself,  necessarily  gave  rise  to  a  new  degree  of  contraction.  The 
lagophthalmos  arising  from  caries  of  the  roof  of  the  orbit,  is  occa- 
sionally attended  by  a  considerable  transverse  elongation  of  the  eye- 
lid, at  the  same  time  that  it  is  drawn  up  into  an  angle,  and  im- 
movably fixed  in  the  elevated  position.  Under  these  circumstances, 
it  has  occurred  to  me  that  an  operation  similar  to  that  which  is 
practised  for  the  worst  degree  of  eversion,  might  be  performed  with 
advantage ;  namely,  cutting  out  a  triangular  portion  of  the  whole 
thickness  of  the  eyelid,  detaching  the  lid  as  completely  as  possible 
from  the  roof  of  the  orbit,  and  then  bringing  the  edges  of  the  wound 
together  by  stitches,  so  as  to  make  the  lid  sit  close  on  the  eyeball, 
and  thus,  by  the  transverse  shortening  produced  by  the  operation, 
counteracting  any  tendency  which  the  lid  might  have  again  to  be- 
come perpendicularly  shortened.  Of  course,  nothing  of  this  sort 
should  be  attempted  till  the  bone  is  perfectly  sound. 

As  palliative  means,  in  all  cases  of  lagophthalmos,  may  be  men- 
tioned, the  lunar  caustic  solution,  which,  applied  once  a-day  to  the 
conjunctiva,  lessens  the  tendency  to  inflammation,  caused  by  the 
exposed  state  of  the  eye  ;  and  the  use  of  such  mechanical  means  as 
may  moderate  the  access  of  hght  and  air. 


'SECTION    XXIII. ECTROPIUM,  OR    EVERSION    OF  THE    EYELIDS. 

1.  Eversion  of  either  lid,  from  inftammation  and  strangulation. 

This  first  variety  of  eversion  takes  place  only  when  the  con- 
junctiva is  in  a  state  of  acute  inflammation.  When  it  affects  the 
upper  lid,  it  is  in  some  measure  accidental.  A  child,  for  example, 
is  labouring  under  acute  puro-mucous  ophthalmia ;  the  attendant, 
upon  attempting  to  look  at  the  eye,  or  to  remove  the  copious  puru- 
lent discharge,  unfortunately  turns  the  upper  eyelid  inside  out : 
the  child  begins  to  cry  violently,  this  increases  the  eversion,  and  all 
attempts  to  reduce  the  lid  to  its  natural  position  are  found  to  be  in- 
effectual. It  is  allowed  to  remain  everted  for  some  hours,  or,  as  I 
have  repeatedly  seen  it  happen,  for  several  days,  and  then  the  child 
is  brought  for  advice.  The  everted  lid  is  by  this  time  greatly  in- 
jected with  blood ;  sometimes  to  such  a  degree,  that  all  attempts  by 
pressure  fail  to  overcome  the  eversion  ;  or  if  we  succeed  in  restoring 
the  lid  to  its  natural  position,  it  very  probably  returns  to  the  state 
of  eversion,  the  moment  that  the  child  begins  to  cry. 

When  this  variety  of  eversion  affects  the  lower  lid,  there  is  noth- 
ing accidental  in  its  production  ;  it  is  entirely  the  result  of  the 
swelling  and  protrusion  of  the  inflamed  conjunctiva. 

The  contagious  or  Egyptian  ophthalmia,  and  the  ophthalmia 
neonatorum,  are  the  most  frequent  sources  of  this  variety  of  ever- 
sion. 

19 


146 

Treatment.  We  have  recourse,  in  the  first  instance,  to  scarifi- 
cation of  the  everted  conjunctiva.  After  the  tumefaction  of  the 
eyehd  is  somewhat  reduced  by  the  discharge  of  blood,  we  are  in 
general  able  to  return  it  to  its  natural  position,  laying  hold  of  it  in 
such  a  manner  as  to  press  out  from  it  as  much  as  possible  of  the  thin  i 
fluid  effused  into  its  substance,  and  suddenly  bending  its  edge,  if  it  be 
the  upper  lid,  downwards  and  backwards.  If  the  state  of  inflam- 
mation is  not  very  acute,  we  ought  to  maintain  the  lid  in  its  natu- 
ral position  by  means  of  a  compress  and  roller.  If  the  ophthal- 
mia be  still  severe,  we  must  content  ourselves  with  recommending 
great  care  in  the  attendants  to  avoid  whatever  might  cause  the 
child  to  cry,  and  instruct  them  in  the  manner  of  reducing  the 
eversion,  should  it  happen  to  return.  From  day  to  day,  or  more 
frequently  than  once  a  day,  if  this  is  thought  necessary,  the  e3'^e  is 
to  be  examined,  and  the  proper  means  applied  to  the  conjunctiva 
for  removing  the  ophthalmia,  as  lunar  caustic  solution,  sulphas  cu- 
pri,  and  the  like. 

I  have  seen  repeated  instances  in  which  scarification  failed,  or  if 
we  succeeded  by  its  means  in  lessening  the  degree  of  eversion,  it 
speedily  returned.  In  such  cases,  we  must  have  recourse  to  the 
removal  of  a  portion  of  the  diseased  conjunctiva.  With  a  hook,  or 
a  pair  of  hooked  forceps,  we  lay  hold  of  the  middle  of  the  exposed 
and  thickened  portion  of  that  membrane,  and  remove,  with  the 
scissors,  a  fold  of  it  of  the  shape  of  a  myrtle  leaf.  The  wound 
bleeds  profusely,  and  this  assists  in  reducing  the  lid  to  a  state  fa- 
vourable for  replacement.  Sti'ips  of  plaster,  passing  from  the  up- 
per to  the  lower  lid,  and  a  compress  and  bandage,  are  then  ap- 
plied, and  are  to  be  removed  from  time  to  time,  till  the  cure  is 
complete. 

Prognosis.  It  is  important  to  observe,  that  although  in  every 
case  of  this  variety  of  Reversion,  our  prognosis  may  be  favourable 
regarding  the  mere  eversion,  we  must  pronounce  nothing  regard- 
ing the  vision  of  the  patient,  unless  we  are  able  distinctly  to  bring 
the  cornea  into  view.  In  neglected  cases,  the  sw^elling  of  the 
everted  conjunctiva  may  be  such,  that  we  shall  find  it  impossible  to 
do  this,  on  our  first  examination  of  the  eye ;  and  under  such  cir- 
cumstances w^e  ought  to  forewarn  the  friends  of  the  patient  that 
we  can  promise  nothing  regarding  the  sight.  After  the  use  of 
scarification  and  other  means,  we  bring  the  cornea  into  view,  but 
not  unfrequently  we  find  the  eye  staphylomatous,  and  of  course 
vision  lost. 

2.  Eiiersion  of  the  loiver  lid  from  relaxation. 

There  occurs  not  unfrequently,  especially  in  old  persons,  an 
eversion  of  the  lower  hd,  as  a  consequence  of  chronic  inflammation 
of  the  conjunctiva  and  Meibomian  follicles.  The  orbicularis  pal- 
pebrarum appears  to  have  lost  its  power  of  supporting  the  lid,  and 
the  tensor  tarsi,  being  also  weakened,  allows  the  punctum  lachry- 


147 

male  to  fall  forwards.  The  exposed  conjunctiva  is  swollen,  of  a 
pale  red  colour,  and  sensible  to  the  touch.  Gradually,  from  the 
constant  influence  of  the  air  upon  a  part  not  intended  to  be  exposed 
to  this  excitement,  and  the  occasional  contact  of  external  bodies, 
the  inside  of  the  everted  lid  becomes  redder,  firmer,  and  almost  in- 
sensible to  the  contact  of  those  substances  which  formerly  excited 
pain  or  brought  on  bleeding  from  its  surface.  The  consequences 
of  this  disease  are  stillicidium  lachrymarum,  and  occasional  attacks 
of  inflammation  of  the  eyeball.  Both  these  are  the  unavoidable 
eflfects  of  the  interruption  of  the  natural  functions  of  the  lower  eye- 
lid. In  the  state  of  eversion,  it  no  longer  covers  completely  and 
accurately  the  inferior  part  of  the  eyeball,  which  consequently  re- 
mains exposed  to  innumerable  causes  of  irritation,  from  which  it 
ought  to  be  guarded.  In  this  state  also,  the  tears  are  no  longer 
guided  onwards  to  the  punctum  lachrymale  by  the  edge  of  the  eye- 
lid, nor  is  the  punctum  kept  in  contact  with  the  eyeball  as  it  is  in 
health,  so  that  the  tears  are  allowed  to  drop  over  on  the  cheek. 

Treatment.  Besides  removing  the  inflamed  state  of  the  lids 
and  conjunctiva,  which  gives  rise  to  this  variety  of  eversion,  we 
find  that  the  application  of  escharotics  to  the  exposed  conjunctiva 
is  the  most  effectual  means  of  counteracting  the  tendency  to  mis- 
placement. The  sulphas  cupri,  and  the  nitras  argenti,  solid  or  in 
solution,  are  to  be  preferred.  Scarification  of  the  inflamed  con- 
junctiva is  also  useful,  as  well  as  keeping  the  lid  raised  into  its  nat- 
ural position,  by  means  of  a  compress  and  roller,  very  carefully 
applied. 

Inveterate  cases  require  for  their  cure  that  a  considerable  portion 
of  the  relaxed  and  thickened  conjunctiva  should  be  removed.  In 
order  to  execute  this  operation  with  exactness,  it  is  necessary  to  cal- 
culate beforehand  what  amount  of  contraction  of  the  conjunctiva 
would  be  sufficient  to  reinstate  the  eyelid  in  its  natural  position.  If 
we  remove  too  little,  a  degree  of  eversion  will  remain.  If  we  remove 
too  much,  we  produce  a  new  disease,  namely,  inversion,  which  is 
at  least  as  bad  as  that  which  we  had  been  endeavouring  to  relieve. 
The  operation  and  after-treatment  are  the  same  as  have  already  been 
mentioned  under  the  first  variety  of  eversion.  If  our  calculation  in 
the  quantity  of  conjunctiva  to  be  removed  has  been  correct,  we  find 
the  ectropium  cured  as  soon  as  the  cicatrice  is  completed. 

3.  Eversion  of  the  lower  lid,  from  excoriation. 

The  most  common  cause  of  eversion  is  excoriation  of  the  lower 
lid  and  cheek,  in  consequence  of  long-continued  ophthalmia  tarsi. 
We  find  the  edges  of  the  everted  lid  rounded  off,  the  Meibomian 
apertures  partially  or  totally  obliterated,  the  cilia  destroyed,  and  a 
considerable  portion  of  inflamed  conjunctiva  permanently  exposed  to 
view. 

Treatment.  We  endeavour  to  remove  the  remaining  symptoms 
of  the  ophthalmia  tarsi,  by  the  means  of  cure  already  recommended. 


148 

The  skin  of  the  everted  lid  is  to  be  softened,  and  protected  from 
farther  irritation,  by  the  frequent  application  of  simple  cerate,  or  ox- 
ide of  zinc  ointment.  Scarification  of  the  exposed  conjunctiva,  and 
the  application  of  fluid  and  solid  escharotics.  especially  the  sulphas 
cupri  and  nitras  argenti,  will  do  much  both  to  remove  the  inflam- 
mation and  restore  the  natural  position  of  the  lid.  Should  these 
means  not  prove  completely  effectual,  a  portion  of  the  conjunctiva 
must  be  extirpated,  as  has  been  already  recommended  for  the  first 
and  second  varieties  of  eversion  :  or  destroyed  by  a  very  cautious 
application  of  sulphuric  acid.  In  very  bad  cases  of  this  sort  we 
may,  with  advantage,  have  recourse  to  the  removal  of  a  portion  of 
the  whole  thickness  of  the  lid,  of  the  shape  of  the  letter  V,  an  ope- 
ration recommended  by  Sir  William  Adams,*  and  which  we  are 
frequently  obliged  to  practise  in  eversion  arising  from  a  cicatrice. 

4.  Eversion  of  the  lower  lid  from  disunion  at  the   temporal 
angle  of  the  lids. 

This  variety  of  eversion  seldom  occurs  except  in  those  pretty  far 
advanced  in  life,  and  who,  for  a  long  time,  have  been  aflfected  with 
inflammation  of  the  edges  of  the  lids.  A  succession  of  ulcers  at 
their  outer  angle  at  length  efiects  their  disunion,  and  allows  the  low- 
er lid  to  become  everted. 

Treatment.  In  this  variety  of  eversion,  an  operation  similar  in 
principle  to  that  for  harelip,  has  been  recommended,  namely,  the 
removal  of  the  edges  of  the  ulcerated  and  disunited  commissure  of 
the  lids,  which  are  then  to  be  brought  into  contact,  and  healed  by 
the  first  intention.  Such  an  operation  appears  to  be  the  only  means 
of  cure  for  this  variety  of  eversion  ;  but  of  course  v^e  need  not  think 
of  performing  it  till  all  appearances  of  ulceration  and  inflammation 
of  the  lids  have  completely  subsided.  These  being  the  original 
causes  of  the  disease  would  completely  thwart  our  attempts  for  its 
cure. 

5.  Eversion  of  either  lid.,  from,  a  cicatrice. 

The  cicatrice  which  operates  in  the  production  of  this  variety  of 
eversion,  may  be  the  consequence  of  a  w'ound,  an  abscess,  an  ulcer, 
or  a  burn. 

Not  even  the  simplest  incision  can  be  healed  without  some  de- 
gree of  induration  and  contraction  in  the  parts  immediately  sur- 
rounding the  cicatrice.  In  cases  of  abscess  opening  externally,  we 
observe  that  the  whole  circumference  of  the  abscess  contracts,  till  lit- 
tle or  no  cavity  is  left,  and  that  when  the  cure  is  completed,  instead 
of  the  elevation  which  existed  when  the  abscess  was  filled  with  pus, 
the  surface  presents  an  evident  depression.  In  the  middle  of  this 
depression  is  the  cicatrised  wound  by  which  the  abscess  was  laid 
open,  and  we  find  the  skin  drawn  towards  the  cicatrice  and  render- 
ed unnaturally  tense  by  this  contraction.     In  cases  of  ulcers  and 

♦  Practical  ObserTations  on  Ectropium,  &c.     London,  1814. 


149 

burns,  in  which  a  considerable  portion  of  skin  has  been  destroyed, 
these  phenomena  are  still  more  striking.  Though  nature  contrives 
to  cover  up  an  ulcer  by  a  process  of  cicatrization,  and  to  produce,  in 
place  of  the  portion  of  skin  which  had  been  destroyed,  a  supplemen- 
tary substance,  yet  matters  are  not  restored  exactly  to  their  former 
state.  The  ulcer  is  covered,  partly  at  the  expense  of  the  surround- 
ing sound  skin  which  is  drawn  together  and  contracted  over  the 
sore,  and  partly  by  the  formation  of  a  new  membrane,  which,  though 
we  give  it  the  name  of  skin,  possesses  but  few  of  the  properties  of 
the  old  integuments.  It  is  neither  so  large  as  the  piece  of  skin 
which  has  been  lost,  nor  is  it  so  yielding,  nor  so  elastic,  nor  so 
moveable  upon  the  part  which  it  covers.  It  is  smooth  and  shining, 
and  scarcely  capable  of  distention,  but  above  all,  so  far  as  the  pre- 
sent subject  is  concerned,  the  surrounding  original  cutis  is  drawn 
towards  this  supplementary  production,  is  puckered  and  thrown  into 
folds,  and,  to  use  the  homely  comparison  of  Mr.  Hunter,  the  whole 
appears  as  if  a  piece  of  skin  had  been  sewed  into  a  hole  by  much 
too  large  for  it,  and  therefore  it  had  been  necessary  to  throw^  the 
surrounding  old  skin  into  folds,  or  gather  the  surrounding  skin,  in 
order  to  bring  it  into  contract  with  the  new. 

To  apply  these  facts  to  the  subject  before  us,  if  merely  an  incis- 
I  ion,  for  instance,  be  made  below  the  edge  of  the  under  eyelid,  a 
degree  of  induration  and  contraction  will  infaUibly  result,  and  the 
edge  of  the  lid  will  be,  though  perhaps  in  a  very  small  degree, 
permanently  drawn  downwards.  If  an  abscess  take  place  in  the 
same  situation,  a  considerable  depression  will  be  left  after  it  is  evac- 
uated and  cured,  the  integuments  will  be  contracted  towards  the 
cicatrice  which  closes  the  opening  of  the  abscess,  and  a  still  greater 
degree  of  displacement  than  in  the  case  of  simple  \vound,  with 
some  degree  of  eversion,  will  be  produced.  In  the  case  of  an  ulcer 
or  a  burn,  the  degree  of  eversion  is  in  exact  proportion  to  the  situ- 
ation of  the  cicatrice  and  the  loss  of  substance  which  had  been 
produced.  Nay,  there  is  a  greater  degree  of  contraction  when  these 
accidents  take  place  in  the  eyelids  than  if  they  had  happened  in  sev- 
eral other  parts  of  the  body,  where  the  integuments  are  more  on  the 
stretch.  The  eyelids  are  so  loose,  that  very  httle  new  skin  is 
formed,  the  cicatrice  is  proportionally  smaller,  the  contraction 
greater,  and  the  eversion  more  considerable. 

Treatment.  Such  being  the  origin  of  this  variety  of  eversion,  it 
comes  to  be  a  question,  how  far  it  is  curable,  or  in  other  words, 
whether  there  be  any  method  of  removing  or  diminishing  the  con- 
traction attendant  on  cicatrization. 

This  contraction,  so  far  from  diminishing,  increases  gradually 
for  some  time  after  the  process  of  cicatrization  has  been  completed, 
the  granulations  becoming  absorbed,  by  which  the  closure  of  the 
wound  was  in  some  measure  effected,  and  on  which  the  new  skin 
was  formed.  Matters  then  appear  for  a  while  to  remain  stationary, 
1  but  in  the  course  of  the  ensuing  years,  and  in  consequence  of  the 


150 

mechanical  motion  to  which  the  parts  are  subject,  a  slight  increase 
takes  place  in  the  flexibility  of  the  cicatrized  surface,  and  it  becomes 
somewhat  less  firmly  attached  to  the  parts  which  it  covers.  The 
parts,  which  were  at  first  matted  immoveably  together,  yield  a  little 
to  the  motions  impressed  on  them  by  external  causes,  and  the 
absorbents  appear  to  contribute  to  this  slight  relaxation,  by  re- 
moving some  of  the  adventitious  substance  which  bound  the  in- 
tegumems  to  the  parts  beneath.  This  is  all  the  return  which  is 
ever  made  to  the  natural  state  by  the  action  of  the  part  themselves. 
The  everted  eyelid,  after  some  years,  will  have  loosened  itself  a  fc 
very  little  from  its  unnatural  situation,  and  not  quite  so  nmch  o] 
the  eyeball  will  now  be  exposed  as  was  the  case  immediately  after 
the  completion  of  the  process  of  cicatrization. 

The  hand  of  art,  however,  has  sought  to  relieve  not  only  the 
present  variety  of  eversion,  but  similar  consequences  of  cicatrization 
in  various  parts  of  the  body,  by  a  more  speedy  and  effectual  method. 
Celsus  gives  us  a  very  distinct  account  of  the  operation,  practised 
in  his  time,  for  the  cure  of  this  kind  of  eversion.*  When  the  dis- 
ease was  situated  in  the  upper  eyelid,  an  incision,  down  to  the 
cartilage,  was  made,  in  the  form  of  a  crescent,  the  extremities  of 
which  were  turned  downwards.  When  the  disease  affected  the 
lower  lid,  an  incision  of  the  same  form  w^as  made  there,  the  extrem- 
ities still  pointing  downwards.  The  edges  of  these  incisions  were 
kept  open  as  much  as  possible,  by  means  of  Unt  put  into  the  wound, 
so  that  they  healed  up  by  a  slow  process  of  granulation  and  cica- 
trization- It  was  expected  that  the  space  between  the  edges  of 
the  incision  would  be  filled  up  by  new  substance,  that  the  eyelid 
would  consequently  be  considerably  elongated,  that  the  edge  would 
return  to  its  natural  position,  or  in  other  words,  that  the  eversion 
would  be  cured. 

This  operation  was  frequently  tried  in  later  times,  but  so  far 
from  permanently  curing  eversion,  it  was  found  in  the  end  to  in- 
crease the  very  disease  it  was  performed  to  relieve.  Immediately 
after  the  incision,  indeed,  the  eyelid  can  be  brought  nearly,  if  not 
altogether,  into  its  natural  situation  ;  so  long  as  the  processes  of  gran- 
ulation and  cicatrization  are  going  on,  the  case  continues  at  least 
much  better  than  it  had  been  before;  but  as  soon  as  the  cure  is 
pronounced  complete,  it  is  found  that  the  eversion  begins  to  return, 
and  that  at  the  end  of  perhaps  a  year,  matters  are  rather  worse 
than  they  were  before  the  operation. 

The  following  case,  by  Bordenave,  sufficiently  illustrates  both 
the  failure  of  this  operation,  and  the  good  effects  of  extirpating  a 
portion  of  the  conjunctiva,  in  this  variety  of  eversion. 

A  young  man,  aged  21  years,  had  eversion  of  the  right  lower 
eyelid,  from  a  cicatrice,  the  consequence  of  a  burn  of  the  face, 
which  had  happened  during  infancy.  The  eversion  was  consid- 
erable, the  internal  part  of  the  eyehd  protruding  presented  a  red- 

*  De  Re  Medica,  Lib.  VII.  Cap.  i.  Sect.  2. 


151 

ness  which  was  disagreeable  to  look  at,  and  the  eye  could  not  be 
covered  by  bringing  the  lids  together.  Bordenave  examined  the 
state  of  parts,  and  found  the  cicatrice  considerably  flexible.  He  be- 
lieved himself  justified  in  hoping  to  cure  it  by  the  ordinary  opera- 
tion, which  he  performed  some  days  afterwards,  according  to  the 
prescribed  rules.  Having  made  a  semilunar  incision  of  moderate 
depth,  below  the  tarsus,  he  separated  the  lips  of  the  wound  with 
charpie,  and  kept  them  in  this  state  by  adhesive  plasters,  com- 
presses, and  a  suitable  bandage.  Some  days  afterwards,  suppura- 
tion established  itself.  The  eyelid  appeared  extremely  relaxed,  it 
covered  almost  entirely  the  eye,  and  the  cure  seemed  certain.  But 
these  appearances  of  success  were  not  of  long  duration  ;  the  cica- 
trice being  completed,  and  the  eyelid  no  longer  restrained,  things 
returned  to  their  former  state.  Not  convinced,  however,  of  the 
faultiness  of  the  operation,  Bordenave  believed  that  he  had  not 
performed  it  with  sufficient  exactness  ;  and  therefore  he  repeated  it, 
but  with  no  better  success.  He  says,  that  he  should  have  despaired 
of  curing  the  case,  had  not  the  patient's  eagerness  to  be  relieved, 
forced  him  in  some  manner  to  try  a  different  treatment.  Seeing 
that  he  was  unable  to  elongate  the  eyelid,  in  order  to  conceal  the 
everted  conjunctiva,  he  resolved  to  remove  a  portion  of  this  mem- 
brane in  almost  all  its  length.  This  he  did  with  a  straight  bis- 
toury, and  found  it  exceedingly  useful.  Some  time  after,  the 
conjunctiva  still  protruding  a  little,  he  practised  a  second  section, 
which  had  all  the  success  desired.  In  proportion  as  the  conjuncti- 
va cicatrized,  the  eyelid  returned  to  its  proper  direction,  it  applied 
itself  more  immediately  upon  the  eye,  at  last  the  eye  closed  itself 
much  better,  and  the  deformity  became  scarcely  visible.* 

In  slight  cases,  then,  of  eversion,  arising  from  a  cicatrice,  this 
simple  operation  of  removing  a  fold  of  the  conjunctiva  may  be 
sufficient.  In  worse  cases,  it  may  be  proper  to  combine  the  old 
operation,  of  dividing  the  cicatrice,  with  this  method  of  counteract- 
ing the  eversion,  by  anew  cicatrice  on  the  inside  of  the  lid.  There 
are  cases,  however,  of  this  variety  of  eversion,  which  neither  of 
these  plans  is  sufficient  to  remedy.  We  meet  with  cases,  in 
which  the  degree  of  eversion  is  very  great,  the  eyelid  dragged 
much  from  its  natural  position,  its  length  in  the  transverse  direc- 
tion much  increased,  and  its  outer  surface  bound  down  unnatu- 
rally by  adhesions.  The  division  of  the  cicatrice,  so  as  to  loosen 
the  lid  from  its  unnatural  situation,  is  the  first  step  to  be  taken  for 
the  relief  of  such  a  case  ;  next,  a  portion  of  the  conjunctiva  may 
be  removed ;  but  in  order  to  counteract  the  morbid  elongation  of 
the  lid  from  the  one  canthus  to  the  other,  it  is  necessary  to  remove 
a  portion  of  its  whole  thickness,  of  the  shape  of  the  letter  V,  and 
then  bring  the  edges  of  the  wound  together  by  a  stitch  or  two. 
This  makes  the  lid  again  sit  close  upon  the  eyeball,  as  in  health, 
and  completely  cures  the  eversion. 

*  Memoiresde  I'Acadeniie  de  Chirurgie.  Tome  xiii.  p.  170.  13mo.     Paris,  1774, 


152 

It  occasionally  happens  from  an  extensive  burn,  that  both 
eyelids  are  everted,  and  dragged  towards  the  temple.  In  such 
cases,  besides  dividing  the  cicatrice,  removing  part  of  the  exposed 
conjunctiva,  and  perhaps  cutting  out  a  portion  of  the  whole  thick- 
ness of  one  or  of  both  lids,  it  has  been  found  useful  to  pare  away 
a  small  portion  of  the  edge  of  each  hd  at  their  outer  angle,  and 
then  to  bring  the  two  together  by  a  stitch.  This  tends  to  reduce 
the  opening  between  the  lids  to  its  natural  length,  and  removes 
much  of  the  deformity. 

5.  Eversion  from  caries  of  the  orbit. 

I  have  already  had  occasion  to  refer  to  this  variety  of  eversion, 
and  to  the  great  degree  of  shortening  of  the  lid  with  which  it  is 
in  general  attended.*  There  is  one  circumstance  upon  which  I 
have  perhaps  not  sufficiently  insisted,  which  we  may  remark  more 
or  less  in  every  variety  of  eversion,  but  which  is  often  very  strik- 
ingly displayed  in  those  cases  where  the  upper  lid  is  dragged  up 
under  the  edge  of  the  orbit  from  an  affection  of  the  bone,  namely, 
the  degree  of  accommodation  of  the  lower  hd  to  the  deficient  state 
of  the  upper.  In  the  act  of  winking,  the  lower  lid  is  thrust  up  by 
the  contraction  of  the  orbicularis  palpebrarum,  so  as  to  meet  the 
upper,  and  almost  to  cover  the  eye. 

As  to  the  treatment,  I  have  nothing  to  add  to  what  I  have  said 
under  the  head  of  lagophthalmos. 


SECTION  XXIV. TRICHIASIS  AND  DISTICHIASIS. 

Trichiasis  is  an  inversion  of  the  eyelashes  ;  distichiasis,  a  double 
row  of  eyelashes. 

Syinptoms.  We  very  seldom  find  all  the  eyelashes  turned 
towards  the  eyeball,  except  when  the  trichiasis  is  merely  a  symp- 
ton  of  inversion  of  the  edge  of  the  eyelid,  a  disease  which  we  leave 
out  of  view  for  the  present,  and  even  when  it  is  a  symptom  of  in- 
version of  the  edge  of  the  eyelid,  the  trichiasis  sometimes  remains 
partial.  In  the  same  manner,  the  pseudo-cilia  which  are  produced 
in  distichiasis,  seldom  occupy  the  whole  length  of  the  eyehd,  but 
in  most  cases  are  strewed  here  and  there  in  parcels,  between  the 
natural  place  of  the  cilia  and  the  Meibomian  apertures.  Both  these 
diseases,  especially  when  only  one  or  two  small  colourless  e5^elashes 
are  inverted,  are  apt  to  escape  being  noticed,  and  those  diseased 
appearances  of  the  eyeball  which  are  owing  to  their  irritation,  are 
supposed  to  be  occasioned  b}^  some  disorder  of  the  eyeball  itself. 
Means  are  directed  against  the  effects  while  the  cause  is  overlooked, 
and  the  eye  may  be  seriously  injured,  and  even  vision  lost,  from  a 
derangement  which  on  a  superficial  view  appears  trivial.  In  every 
case  in  which  the  patient,  after  an  attack  of  ophthalmia,  recovers  ■ 

*  See  pages  34  and  144. 


153 

with  extreme  slowness,  the  surface  of  the  cornea  continuing  dim 
and  strewed  with  blood-vessels,  and  the  eye  discharging  tears  upon 
the  smallest  increase  of  light,  we  ought  carefully  to  examine  the 
edges  of  the  eyelids,  and  discover  whether  any  of  the  eyelashes  be 
inverted,  or  any  false  eyelashes  be  present.  The  false  eyelashes 
are  in  general  so  soft,  short,  and  light-coloured,  that  they  can  be 
seen  only  when  the  eyelids  are  opened  wide,  but  at  the  same  time 
allowed  to  remain  in  contact  with  the  eyeball.  The  moment  that 
the  edge  of  the  lid  is  drawn  forwards  from  touching  the  eyeball, 
the  false  cilia  are  scarcely  or  not  at  all  visible.  On  again  applying 
the  edge  of  the  lid  to  the  eyeball,  they  return  into  view. 

Causes.  Trichiasis  and  distichiasis  are  in  an  especial  manner 
the  consequences  of  neglected  opthalmia  tarsi,  and  strumous  op- 
thalmia.  Small-pox  was  formerly  a  very  abundant  source  of  these 
derangements  of  the  cilia.  In  fact,  every  affection  of  the  lids  at- 
tended wdth  abscesses  and  ulcers  at  the  roots  of  the  eyelashes,  is 
apt  to  give  rise  to  trichiasis  and  distichiasis,  especially  if  the  patient 
is  allowed  to  lie  much  on  the  face,  so  that  the  cilia,  loaded  with 
mucus,  or  matted  together  by  the  diseased  secretion  of  the  Meibom- 
ian follicles,  are  forced  into  a  constant  direction  towards  the  eyeball. 

Prognosis.  If  there  be  no  degeneration  of  the  edges  of  the  eye- 
lids present,  the  prognosis  in  trichiasis  may  be  favourable.  Disti- 
chiasis, on  the  other  hand,  can  very  seldom  be  radically  cured  ;  and 
even  as  seldom  can  trichiasis,  when  connected  with  evident  altera- 
tions in  the  edges  of  the  lids. 

Treatment.  All  the  proposals  which  have  been  made  for  re- 
storing the  cilia  in  trichiasis  to  their  proper  direction,  as,  constantly 
turning  them  outwards,  keeping  the  lids  everted  by  adhesive  plas- 
ters, &c.  are  of  as  little  value  as  those  for  hindering  the  growth  of 
pseudo-cilia,  namely,  the  appUcation  of  escharotics  to  the  edge  of 
the  lids,  the  burning  of  the  foramina  whence  the  eyelashes  issue 
with  a  red-hot  needle,  and  the  like.  From  whatever  causes  trichi- 
asis or  distichiasis  has  originated,  we  must  carefully  remove,  one 
after  the  other,  all  the  inverted  and  misplaced  cilia,  by  means  of  a 
proper  pair  of  forceps.  Each  eyelash  is  to  be  laid  hold  of  as  close 
as  possible  to  the  skin,  and  pulled  out  quickly  in  a  straight  direc- 
tion, in  order  that  it  may  not  break.  Except  when  the  edge  of  the 
lid  is  perfect,  and  the  trichiasis  entirely  the  result  of  the  cilia  having 
been  matted  together  by  mucus,  this  operation  must  be  regarded  as 
merely  palliative.  Carefully  and  frequently  repeated,  it  occasion- 
ally proves,  even  in  cases  of  distichiasis,  especially  in  young  sub- 
jects, a  radical  means  of  cure  ;  but  on  this  we  cannot  depend,  and, 
therefore,  as  soon  as  the  inverted  cilia  or  pseudo-ciha  make  their 
appearance,  they  must  be  extracted.  We  meet  with  patients  who 
:for  many  years  have  been  obliged,  every  two  or  three  weeks,  to 
have  this  repeated. 

The  constant  repetition  even  of  this  trifling  operation  being  found 
by  many  extremely  annoying,  we  are  often  asked  whether  there  is 
20 


154 

no  means  by  which  trichiasis  or  distichiasis  could  be  permanently 
removed  ;  and  with  this  view,  the  operations  for  inversion  of  the 
hds  have  sometimes  been  had  recourse  to. 

False  eyelashes  are  sometimes  met  with  growing  from  different 
parts  of  the  conjunctiva,  even  from  the  conjunctiva  cornese.  Dr. 
Monteath  mentions  a  case,  in  which  one  exceedingly  strong  hair 
grew  from  the  inner  surface  of  the  lower  lid.  It  was  directed  per- 
pendicularly towards  the  eyeball,  and  irritated  it.  The  natural 
cilia  were  of  a  light  colour,  the  pseudo-cilium  jet  black,  and  double 
the  strength  of  the  common  cilia. 

I  once  met  with  an  eyelash  fully  an  inch  long,  soft,  and  woolly, 
in  a  patient  who  had  long  suffered  from  ophthalmia. 


SECTIOX  XXV. ENTROPIUM,  OR    INVERSION    OF    THE  EYELIDS. 

There  are  two  varieties  or  degrees  of  inversion,  which  differ  ma- 
terially in  their  causes,  symptoms,  and  modes  of  cure.  The  one  is 
acute,  the  other  chronic. 

1.  The  acute  variety  generally  takes  its  origin  in  an  attack  of 
ophthalmia,  during  which  the  patient  had  kept  the  eyehds  long 
shut,  or  perhaps  covered  with  a  poultice.  I  have  seen  it  take  place 
during  the  inflammation  following  extraction  of  the  cataract.  The 
lower  lid  is  the  more  frequent  seat  of  this  variety  of  inversion. 
The  skin  of  the  inverted  lid  is  generally  swollen  and  puffy.  Its 
edge  is  perfectly  regular  in  fornj,  not  thickened  nor  indurated,  but 
entirely  rolled  back  towards  the  eyeball,  and  the  eyelashes  fairly 
out  of  view.  On  applying  the  finger  to  the  outer  surface  of  the 
lid,  and  drawing  it  a  little,  the  eyelashes  start  into  view,  chnging  to 
the  surface  of  the  eyeball ;  a  little  more  traction  rolls  the  edge  of 
the  lid  completely  into  its  natural  place,  and  if  we  now  give  over 
dragging  at  the  lid,  it  will  remain  so  for  perhaps  a  minute  or  two, 
and  then  with  a  sudden  jerk,  become  inverted  as  before. 

This  kind  of  inversion  appears  to  be  in  part  owing  to  an  irreg- 
ular action  of  the  orbicularis  palpebrarum.  The  principal  part  of 
the  muscle  seems  to  have  lost  its  wonted  power  of  supporting  the 
body  of  the  lid,  while  its  ciliary  edge  continuing  to  act  rolls  the 
lid  into  the  inverted  position. 

The  conjunctiva  of  the  eyeball  is  much  irritated  by  the  eyelashes 
rubbing  against  it  in  the  act  of  winking,  and  hence  the  patient 
keeps  the  eye  shut,  and  as  much  as  possible  at  rest.  The  corneal 
conjunctiva  becomes  inflamed  ;  and  the  consequence  of  neglecting 
the  inversion,  may  be  total  opacity  of  the  cornea. 

2.  The  other  variety  of  inversion  is  the  result  of  long-continued 
ophthalmia  tarsi,  or  chronic  catarrhal  inflammation  of  the  conjunc- 
tiva. The  upper  lid  is  equally  liable  to  be  affected  with  the  lower, 
and  often  both  are  inverted  at  the  same  time.  The  edge  of  the 
affected  lid  is  thickened,  irregukir  and  notched,  and  shortened  from ' 


155 

canthus  to  canthus.  No  degree  of  traction  which  we  employ  is 
sufficient  to  roll  the  inverted  lid  into  its  natural  situation  ;  we  may 
drag  it  from  the  eyeball,  and  bring  the  cilia  into  view,  but  still  the 
edge  of  the  lid  continues  inverted.  The  cilia  are  generally  few  in 
number,  and  dwarfish  from  disease.  Still,  they  are  sufficient  to 
keep  up  constant  uneasiness,  and  by  the  irritation  which  they  oc- 
casion, to  render  the  cornea  vascular  and  nebulous.  At  length, 
the  cornea  becomes  quite  opaque,  and  its  conjunctival  layer  acquires 
a  degree  of  morbid  thickness  and  insensibihty,  which  renders  the 
disease  less  insupportable  in  point  of  pain. 

Irregular  action  of  the  orbicularis  palpebrarum  may  also  have 
to  do  Avith  the  production  of  this  kind  of  inversion,  but  it  is  evident 
that  the  structure  of  the  hd  is  here  much  more  impaired.  Inflam- 
mation has  altered  the  parts  surrounding  the  tarsus,  and  even  the 
cartilage  itself  Repeated  ulcerations  hare  destroyed  the  form  of 
the  edge  of  the  hd,  notched  it  with  cicatrices,  and  permanently 
fixed  it  in  the  state  of  contraction  and  inversion. 

Treatment.  As  the  one  of  these  two  kinds  or  degrees  of  inver- 
sion is  much  less  complicated  in  its  symptoms  than  the  other,  so  is 
the  method  of  cure  for  the  one  simple,  for  the  other  complex. 

We  find,  in  the  first  kind,  that  when  we  take  hold  of  a  transverse 
fold  of  the  skin  of  the  inverted  lid,  the  displacement  is  for  the  time 
removed,  and  the  patient  can  open  and  shut  the  eye  without  dif- 
ficulty, and  without  any  return  of  the  inversion.  Remove,  then, 
this  fold  of  skin,  having  laid  hold  of  it  with  a  pair  of  broad  con- 
vex-edged forceps,  bring  the  edges  of  the  wound  together  by  two 
stitches,  and  as  soon  as  union  is  completed,  the  inversion  will  be 
found  to  be  cured. 

The  portion  of  skin  removed  in  this  way  might  be  destroyed  by 
escharotics.  A  piece  of  wood  dipped  in  sulphuric  acid  is  some- 
times used  for  this  purpose,  being  rubbed  along,  about  the  distance 
of  a  line's  breadth  from  the  edge  of  the  inverted  lid,  till  the  skin 
begins  to  grow  dark.  The  eschar  which  follows  necessarily  con- 
tracts the  skin,  and  tends  to  re-adjust  the  position  of  the  inverted 
lid.  If  this  is  not  effected  by  the  first  apphcation,  a  second  or  a 
third  may  be  made,  till  the  inversion  is  completely  removed.  At 
each  application  of  the  sulphuric  acid,  care  must  be  taken,  by  dry- 
ing the  portion  of  skin  which  has  been  touched,  that  none  of  the 
caustic  flows  in  on  the  eye. 

In  the  second  kind  of  inversion,  neither  the  operation  just  de- 
scribed, nor  the  application  of  escharotics,  is  of  any  use.  Portion 
after  portion  of  the  skin  may  thus  be  removed,  but  the  inversion 
continues  as  before.  The  altered  condition  of  the  tarsus  prevents 
the  lid  from  resuming  its  natural  position.  The  tarsus,  then,  must 
be  attacked.  Some  have  cut  it  out  altogether  ;  others  have  pared 
away  its  edge,  removing  in  this  way  that  part  of  the  lid  whence 
the  cilia  grow,  as  well  as  the  Meibomian  apertures.  I  remember 
having  seen  a  Jew  girl  in  Vienna,  who  had  been  operated  on  in 
I  this  manner,  by  Dr.  C.  Jaeger.     The  pain  and  inflammation  of 


156 

the  eye,  and  the  opacity  of  the  cornea,  caused  by  the  inversion, 
were  of  course  removed,  and  the  deformity  produced  by  this  cur- 
taihiient  of  the  hds  was  very  trifling.  A  perpetual  Hppitudo,  how- 
ever, must  follow  the  obliteration  of  the  Meibomian  apertures. 
The  operation  proposed  by  Dr.  F.  Jaeger  is  quite  different  both 
from  Mr.  Saunders'  extirpation  of  the  cartilage,  and  from  the  paring 
of  the  edge  of  the  lid  performed  by  Dr.  C.  Jaeger.  It  consists  in 
removing  that  portion  of  the  integuments  in  which  the  cilia  are 
inserted,  leaving  the  cartilage,  and  as  far  as  possible,  the  Meibomian 
apertures,  entire.  I  consider  this  operation  unnecessary  for  the 
cure  of  the  first  degree  of  inversion,  and  inapplicable  to  the  second. 

As  an  evident  shortening  of  the  lid  in  the  transverse  direction 
attends  this  kind  of  inversion,  and  produces  a  degree  of  constriction 
of  the  eyeball,  the  idea  suggested  itself  to  Mr.  Ware,  of  relieving 
the  affected  lid,  by  a  perpendicular  incision  through  its  whole 
thickness,  either  at  its  temporal  extremity,  or  in  its  middle.  Such 
an  incision  would  at  least  release  the  eyeball  from  the  state  of 
pressure  caused  by  the  contracted  lid. 

It  was  probably  from  this  hint  by  Mr.  Ware,  that  Mr.  Crampton 
was  led  to  devise  the  operation  which  is  now  generally  adopted  in 
cases  of  the  second  degree  of  inversion.  Supposing  it  to  be  the 
upper  lid  which  is  effected,  with  a  narrow,  slightly  curved,  and 
sharp-pointed  bistoury,  pushed  through  the  inverted  lid  from  with- 
in outwards,  it  is  to  be  divided  perpendicularly,  for  the  length  of 
about  three  lines,  close  to  its  temporal  extremity.  A  similar  incision 
is  then  to  be  made  at  the  nasal  extremity  of  the  affected  lid,  taking 
care  to  avoid  the  lachrymal  canal.*  These  incisions  being  made, 
the  eyelid  immediately  feels  unconfined,  it  can  be  raised  from  the 
eyeball,  and  the  patient  is  already  freed  from  a  great  part  of  his 
uneasiness.  Were  we  now  to  leave  the  lid  to  itself,  it  would 
speedily  resume  its  former  place,  the  incisions  by  which  we  had 
liberated  it  would  unite  by  the  first  intention,  and  no  permanent 
relief  would  be  effected.  To  prevent  immediate  union,  Mr.  C. 
employed  an  instrument  similar  to  Pellier's  speculum,  by  which 
he  kept  the  eyelid  constantly  suspended,  and  permitted  only  a  slow 
union  by  granulation.  Instead  of  the  speculum.  I  have  always 
recommended  that  a  fold  of  the  skin  of  the  affected  lid  should  be 
removed,  exactly  as  in  the  operation  for  the  first  kind  of  inversion. 
The  edges  of  the  wound  made  by  the  removal  of  this  fold  are  then 
to  be  brought  together  by  two  or  three  stitches.  The  perpendicu- 
lar incisions  slowly  fill  up  by  granulation ;  the  slower  the  better ; 
the  union,  when  at  length  completed,  does  not  comprehend  the 
orbicularis  palpebrarum ;  the  divided  fibres  of  the  muscle  shrink, 
hke  the  divided  ends  of  every  other  muscle  ;  the  diseased  cartilage 

*  Mr.  Crampton  cut  through  the  lachrymal  canal ;  but  ever  since  I  began  to  give 
lectures  on  the  Eye,  in  1818,  1  have  directed  this  to  be  avoided.  I  have  always  dis- 
countenanced also  the  transverse  incision  of  the  conjunctiva,  recommended  by  Mr. 
C,  and  particularly  insisted  on  the  propriety  of  following  up  the  first  steps  of  Mr. 
C.'s  operation,  by  the  extirpation  of  a  transverse  fold  of  the  integuments. 


157 

loses  also  much  of  its  induration  and  irregularity,  and  thus  the 
lid,  when  re-united,  is  found  improved  in  structure,  and  almost 
natural  in  position. 

I  have  already  mentioned,  that  in  trichiasis  and  distichiasis,  we 
sometimes  have  recourse  to  the  operations  practised  for  the  cure  of 
inversion.  A  fold  of  skin  is  cut  away,  a  portion  is  destroyed  by 
sulphuric  acid,  or  even  Mr.  Crampton's  method  is  adopted.  Tri- 
chiasis and  distichiasis  are  often  partial,  and  when  this  is  ike  case, 
the  corresponding  portion  of  skin  only  is  removed,  or  the  portion 
of  the  edge  of  the  lid  which  bears  the  misplaced  eyelashes  only  is 
insulated  by  two  perpendicular  incisions,  bent  outwards  by  the  ex- 
tirpation of  a  portion  of  the  skin,  and  permitted  to  re-adhere  only  by 
a  slow  process  of  granulation. 


SECTION  XXVI. PHTHEIRIASIS. 

Pediculi  sometimes  lodge  among  the  cilia  and  eyebrow^s,  and 
cause  intolerable  itching.  "A  child  came  to  the  Infirmary,"' 
says  Mr.  Lawrence,  "complaining  of  the  eyes  being  sore,  and 
said  they  itched  very  much.  I  looked  at  the  eye,  and  could  not 
see  much  the  matter,  but  I  thought  that  the  ciUa  had  rather  a 
thick  appearance,  and  on  a  more  accurate  examination,  I  found 
that  this  was  caused  by  an  infinite  number  of  pediculi  sticking 
over  the  hairs.  I  ordered  the  free  apj)lication  of  the  citrine  oint- 
ment, and  wished  to  see  its  effect ;  but  the  mother,  who  came  with 
the  child,  was  so  much  ofiTended  at  being  told  the  cause  of  the 
complaint,  that  she  did  not  bring  the  child  back  again."  *  In  such 
cases,  some  mercurial  salve,  as  that  recommended  by  Mr.  L.,  and 
attention  to  cleanliness,  will  be  effectual. 


SECTION  XXVII. MADAROSIS. 

Neglected  ophthalmia  tarsi  is  apt  to  end  in  the  destruction  of  the 
'  bulbs  of  the  cilia,  which  of  course  cannot  afterwards  be  reproduced. 
Both  the  ciha  and  the  hairs  of  the  eyebrow  are  also  liable  to  fall 
out,  from  different  constitutional  diseases  ;  but  in  this  case  they 
generally  grow  again.     The  want  of  the  eyelashes  and  hairs  of 
the  eyebrow  is  productive  of  frequent  nictitation,  in  order  to  mode- 
rate the  glare  of  day,  and  prevent  the  entrance  of  foreign  particles 
into  the  eye. 
I      I  was  consulted,  some  time  ago,  by  a  man  who  had  lost  every 
'  hair  of  his  body.     His  head  was  perfectly  bald,  he  had  no  eye- 
brows nor  eyelashes,  his  beard  was  gone,  no  hair  in  the  arm-pits, 
on  the  pubes,  nor  on  the  hmbs.     He  was  anxious  to  regain  chiefly 
!  the  eyebrows  and  eyelashes,  as  he  found  his  eyes  much  weakened 
j  by  the  want  of  them.     He  w^as  inclined  to  attribute  his  disease 

I 

:  *  Lectures  ia  the  Lancet,  Vol.  x.  p.  323.    London,  1826. 


158 

to  some  slight  venereal  complaint,  \vhich  he  had  had.  and  which' 
had  been  cured  by  mercury. 

The  treatment,  both  local,  and  general  already  recommended 
for  ophthalmia  tarsi,  must  be  carefully  adopted  in  cases  of  threat- 
ened madarosis.  In  constitutional  cases,  also,  tonics  are  to  be  em- 
ployed both  internally  and  externally,  as  it  is  evident  that  weak- 
ness has  much  to  do  in  the  production  of  this  disease.  Cinchona 
is  particularly  recommended  internally,  and  an  infusion  of  the 
petals  of  the  rosa  centifolia  in  wine  as  a  collyrium.  When  there 
is  a  suspicion  of  syphilis  being  the  cause,  mercury  and  sarsaparilla 
should  be  tried. 


Auchylo-blepharon.   although  strictly  a  disease  of  the  eyelids,  I 
shall  take  up  along  with  sym-blepharon.  in  a  following  chapter. 


CHAPTER  lY. 

DISEASES  OF  THE  TUXICA  CONJUNCTIVA. 

The  principal  morbid  affections  of  the  conjunctiva  fall  under  the 
heads  of  ophthalmia,  and  consequences  of  ophthalmia.  There  are, 
however,  a  few  diseases  of  this  portion  of  the  tutamina  ocuh,  which, 
I  conceive,  it  will  be  convenient  to  introduce  here.  The  tears  flow 
over  the  conjunctiva  ;  we  have  considered  the  diseases  of  the  secret- 
ing lachrymal  organs  ;  this  conducting  organ  of  the  tears  seems  na- 
turally to  claim  our  attention,  before  proceeding  to  the  excreting 
lachrymal  apparatus. 

The  conjunctiva  is  a  muco-cutaneous  membrane,  connected  to 
the  neighbouring  parts  by  cellular  substance.  This  cellular  sub- 
stance is  liable  to  phlegmonous  intiammation,  inflamniatory  cedema 
or  chemosis.  and  to  ecchyrnosis,  and  emphysema :  while  the  con- 
junctiva itself  is  subject  chiefly  to  blenorrhoea  on  the  one  hand,  and 
on  the  other  to  eruptive  inflammations.  We  meet  with  fungus, 
warts,  and  tumours  of  the  conjunctiva.  In  some  cases,  it  seems  to 
lose  its  faculty  of  secreting  mucus,  and  becomes  dry  and  shrivelled ; 
while,  in  other  cases,  its  glandular  structure  is  affected  with  a  mor- 
bid degree  of  development.  The  compound  nature  of  the  mem- 
brane, expressed  by  the  term  juuco-cutaneous,  serves  as  a  key  to  its 
pathology. 


SECTION    I. INJURIES    OF    THE     COXJUXCTIVA,    AND     FOREIGN 

SrSSTAXCES    IN    ITS    FOLDS. 

Fine  dust,  blown  into  the  eye,  may  often  be  removed,  by  pre-' 
ventinof  the  tears  from  beinsr  carried  into  the  lachrvmal  sac.     For 


159 

this  purpose,  pressure  is  to  be  continued  for  some  time,  immediately 
under  the  tendon  of  the  orbicularis  palpebrarum.  In  this  way,  the 
dust  is  washed  by  the  tears  into  the  neighbourhood  of  the  caruncula 
lachrymalis,  whence  they  can  without  difficulty  be  withdrawn  with 
the  finger,  or  with  a  pair  of  small  forceps. 

When  larger  paiticles  of  dust  have  lighted  upon  the  eye,  they 
may  often  be  seen  lying  on  its  surface,  and  are  to  be  removed  with 
the  forceps.  If  they  are  not  visible  on  the  eyeball,  the  lower  lid  is 
first  to  be  drawn  downwards,  when  sometimes  the  foreign  body  will 
come  into  view.  If  nothing  is  discovered  in  the  lower  fold  of  the 
conjunctiva,  then  the  upper  lid  is  to  be  everted.  This  is  done  by 
laying  hold  of  the  eyelashes  with  the  finger  and  thumb,  and  whilst 
by  this  means  the  edge  of  the  lid  is  drawn  outwards  and  upwards, 
a  slight  counterpoise  is  to  be  made  with  a  probe,  on  the  outer  sur- 
face of  the  lid,  opposite  to  the  upper  edge  of  its  cartilage.  Between 
these  two  forces,  the  lid  is  readily  everted,  so  that  its  internal  surface 
is  exposed  ;  and  in  many  cases,  indeed  in  most  cases  in  which  a 
particle  of  dust  lodges  in  the  eye,  a  single  black  point  will  be  ob- 
served adhering  to  the  inside  of  the  lid,  and  can  readily  be  removed. 
The  foreign  particle,  however,  may  be  a  minute  fragrant  of  some 
transparent  substance,  adhering  to  the  inside  of  the  upper  hd,  and 
may  not  be  detected,  unless  with  the  probe  we  go  over  the  surface 
of  the  conjunctiva.  The  pain,  and  spasm  of  the  orbicularis  palpe- 
brarum, which  are  generally  acute,  subside  almost  immediately  on 
the  foreign  body  being  removed. 

Should  it  be  necessary  to  search  for  particles  which  cannot  be 
seen,  a  hair-pencil  dipped  in  some  adhesive  fluid,  as  honey,  may 
assist  US  in  entangling  them  ;  or  the  upper  fold  may  be  washed  out 
by  means  of  a  syringe^and  tepid  water. 

It  is  remarkable,  that  while  the  smallest  particle  of  dust,  fixed  on 
the  inside  of  the  upper  eyelid,  generally  gives  rise  to  intolerable  un- 
easiness, till  it  be  removed,  foreign  bodies  of  considerable  size  may 
lodge  in  the  looser  part  of  the  folds  of  the  conjunctiva  for  many- 
weeks,  without  inducing  any  violent  symptoms.  The  conjunctiva, 
in  such  cases,  is  apt  to  become  fungous,  so  as  even  to  cover  com- 
pletely the  foreign  substance,  and  hide  it  from  view. 

Dr.  Monteath,  in  his  Notes  to  Weller's  Manual,  relates  the  case 
of  a  young  girl,  who  had  a  soft  red  fungus  growing  out  of  the  eye, 
as  large  as  a  filbert.  It  was  of  some  weeks'  standing,  and  was  at- 
tributed to  a  hurt  inflicted  by  a  straw  striking  the  eye.  This  fun- 
gus originated  in  the  conjunctiva,  where  it  is  reflected  from  the  low- 
er eyelid  to  the  eyeball.  It  was  cut  away  ;  but  in  three  weeks  was 
as  large  as  ever.  It  was  again  removed,  and  at  the  angle  of  reflex- 
ion of  the  conjunctiva,  a  bit  of  straw,  hall  an  inch  in  length,  was 
observed  and  extracted.     The  cure  was  complete  in  a  few  days. 

The  same  author  relates  the  case  of  a  man,  who  consulted  him 
on  account  of  an  inflamed  state  of  his  eye,  induced  by  a  fall,  five 
months  before,  among  some  bushes,  in  descending  a  steep  moun- 


160 

tain.  He  felt  some  part  of  his  eye  wounded  at  the  moment,  and 
had  never  enjoyed  freedom  from  a  tender  state  of  it,  from  that  period, 
though  he  had  apphed  a  great  variety  of  medicines.  On  everting 
the  upper  eyehd,  a  fungous  state  of  ihe  conjunctiva  was  discovered 
very  high  up  in  the  angle  of  reflection  of  that  membrane,  and  on 
examination  with  the  probe,  it  was  evident  that  a  foreign  body 
lodged  there.  It  was  laid  hold  of  and  extracted  with  the  forceps, 
and  proved  to  be  a  portion  of  a  twig  of  a  bush,  f  ths  of  an  inch 
in  length,  and  nearly  as  thick  as  a  crow-quill.  This  substance 
had  remained  in  the  upper  fold  of  the  conjunctiva  for  five  months, 
and  had  got  into  that  situation  without  wounding  the  eye. 

The  foreign  bod}'^,  being  hard  and  angular,  may  penetrate  into  the 
conjunctiva,  it  may  gradually  insinuate  itself  under  that  membrane, 
or  it  may  have  been  driven  under  it,  at  once,  by  the  projectile  force 
with  which  it  had  been  sent  against  the  eye.  In  such  cases,  it  is 
sometimes  necessary  to  raise  a  portion  of  the  conjunctiva  with  the  for- 
ceps, and  snip  it  off  along  with  the  foreign  substance.  If  this  is  not 
done,  the  conjunctiva  heals  over  the  foreign  body,  and  the  irritation 
ceases.  Mr.  Wardrop  tells  us,  that  in  one  case  he  found  a  piece  of 
whinstone,  inclosed  in  a  sac  of  cellular  membrane,  lying  close  to 
the  sclerotic  coat,  where  it  had  remained  for  ten  years  prior  to  the 
person's  death,  without  his  experiencing  the  least  uneasiness,  or 
even  suspecting  its  presence. 

If,  after  the  foreign  substance  has  been  removed,  the  spasms  of 
the  orbicularis  palpebrarum  should  still  continue,  which  is  par- 
ticularly apt  to  be  the  case  when  the  conjunctiva  has  been  both  me- 
chanically and  chemically  injured,  the  patient  ought  to  be  removed 
to  a  dark  room,  kept  quiet,  and  a  soft  warm  poultice,  containing 
a  quantity  of  aqueous  solution  of  opium,  applied  over  the  eye,  in 
a  thin  hnen  bag. 

Particles  of  quick  lime,  potash,  and  other  caustic  substances, 
must  immediately  be  extracted  from  the  eye,  with  the  forceps, 
or  any  other  instrument  which  is  at  hand.  When  they  are  in 
the  state  of  powder,  we  are  warned  that  it  is  dangerous  to  remove 
them  by  means  of  water,  because  the  lime  thereby  slaking,  and 
the  caustic  dissolving,  are  apt  to  spread  farther,  and  of  course  to 
produce  more  extensive  injury.  It  is  therefore  recommended  to 
remove  such  substances  by  means  of  a  hair-pencil,  dipped  in  oil 
or  smeared  with  fresh  butter.  Mr.  Guthrie,  however,  judiciously 
observes  that,  were  oil  not  at  hand,  he  should  not  hesitate  to 
force  open  the  lids,  and  cause  a  strong  stream  of  water  to  pass 
between  them,  so  as  to  carry  away  the  lime  without  giving  it  time 
to  do  mischief,  then  to  evert  the  lids,  and  continue  the  same  ope- 
ration until  every  particle  of  the   lime  was   removed. 

Gunpowder  exploded  into  the  eye  fixes  in  the  conjunctiva, 
and  must  be  carefully  picked  out  with  the  point  of  a  needle,  else 
the  membrane  will  close  over  the  grains,  so  that  they  will  remain 
indelible. 


161 

Hot  and  caustic  fluids  blister  the  conjunctiva,  and  bring  on  in- 
flammation of  a  highly  dangerous  character.  A  stream  of  cold  or 
slightly  tepid  water,  injected  over  the  whole  surface  of  the  con- 
junctiva, is  the  remedy  to  be  had  recourse  to  in  the  first  in- 
stance. 

The  stings  of  insects  sometimes  fix  in  the  conjunctiva,  and  are 
to  be  carefully  removed,  either  by  a  pair  of  forceps  or  the  point  of  a 
cataract  needle. 

The  inflammation  of  the  conjunctiva  which  follows  the  various 
injuries  above  enumerated,  is  by  no  means  of  uniform  character. 
Of  course,  rest,  and  the  antiphlogistic  regimen  are  necessary  in  every 
case  of  injury  of  the  eye.  But,  as  I  shall  explain  more  fully,  under 
the  head  of  Traumatic  Ophthalmia,  the  local  applications  must  be 
regulated  by  the  peculiar  symptoms  excited,  and  even  the  internal 
remedies  to  be  employed  are  not  of  that  uniform  sort  with  which 
inflammation,  in  less  complicated  parts  of  the  body,  is  usually 
treated. 


SECTION  II. SUBCONJUNCTIVAL  ECCHYMOSIS. 

Extravasation  of  blood  into  the  subconjunctival  cellular  mem- 
brane occurs  from  various  causes,  as  blows  on  the  eye,  blows  on 
the  eyebrow,  fits  of  coughing,  &c.  I  have  seen  a  slight  blow  on 
the  forehead  produce  ecchymosis  beneath  the  conjunctiva  of  both 
eyes.  In  some  cases,  no  evident  cause  appears  why  the  vessels 
should  have  opened,  for  the  patient  on  awaking  in  the  morning 
finds  the  conjunctiva  of  a  deep  red  colour,  without  any  pain  being 
present,  or  any  thing  having  happened  likely  to  produce  such  an 
effect.  The  extravasated  blood  is  gradually  absorbed,  the  con- 
junctiva becoming  first  yellow,  and  then  resuming  its  natural  ap- 
pearance. A  shghtly  astringent  collyriurn  generally  forms  the 
whole  treatment. 


SECTION  III. SUBCONJUNCTIVAL  EMPHYSEMA. 

We  have  already  explained  how  the  eyelids  are  subject  to  em- 
physema, in  cases  of  fracture  of  the  frontal  sinus,  the  air  passing 
from  the  nostril  through  the  fractured  os  frontis  into  their  cellular 
membrane.  From  similar  injuries,  extending  between  the  nostril 
and  the  orbit,  the  cellular  membrane  which  connects  the  conjunc- 
tiva to  the  neighbouring  parts,  is  sometimes  filled  with  air. 

Should  the  swelling,  arising  from  the  effused  air,  prove  so  great 
as  to  give  rise  to  pain,  or  impede  the  motion  of  the  eyeball  or  eye- 
lids, the  conjunctiva  may  be  punctured,  so  as  to  let  it  escape,  till 
the  fracture  is  supposed  to  be  consolidated.  The  patient  ought  to 
avoid  forcible  blowing  of  the  nose,  by  which  this  emphysema,  as 
well  as  that  of  the  eyehds,  is  apt  to  be  induced. 
21 


162 


SECTION  IV. SUBCONJUNCTIVAL    PHLEGMON. 

The  subconjunctival  cellular  membrane  is  occasionally  the  seat 
of  phlegmonous  inflammation.  The  conjunctiva  in  this  case  is  in- 
jected with  red  vessels,  generally  on  the  temporal  side  of  the  eye. 
the  part  affected  is  much  thickened,  and  after  some  days  presents  c 
prominence  about  the  size  of  a  split  pea,  which  rarely  goes  the 
length  of  suppuration.  This  disease  will  easily  be  distinguished 
from  any  of  the  opthalmiee. 

We  might  suppose  slight  injuries  to  be  the  most  probable  causes 
of  this  complaint ;  but,  in  general,  Uke  phlegmonous  inflammation, 
in  many  other  instances,  it  is  produced  without  any  evident  cause 
In  one  case,  I  observed  subconjunctival  phlegmon  precede  an  attack 
of  syphilitic  iritis  ;  but  this  must  be  extremely  rare. 

Bloodletting  of  any  kind  is  scarcely  ever  necessary  in  this  com- 
plaint. The  patient  should  be  purged.  Warm  fomentations  tc 
the  eye  are  to  be  used.  If  the  phlegmon  goes  on  to  suppuration,  il 
is  to  be  opened  with  the  lancet. 


SECTION  V. PTERYGIUM. 

This  term  is  applied  to  a  disease  w^iich  consists  of  a  thickened 
and  elevated  portion  of  the  conjunctiva  of  the  eyeball,  of  a  triangu- 
lar form,  its  base  generally  turned  to  the  caruncula  lachrymal!- 
while  its  apex  advances  towards  the  edge,  or  stretches  even  as  fai 
as  the  middle  of  the  cornea.  In  some  cases  the  base  of  the  ptery 
gium  is  towards  the  temporal  angle  of  the  eye,  and  occasionally 
both  sides  of  the  eye  are  affected  with  this  disease. 

^ymjitoms.  One  variety  of  pterygium  is  semi-transparent,  and 
thinly  strewed  with  blood-vessels.  This  is  the  iJterygium  tenue. 
Another  variety  presents,  from  the  size  and  course  of  its  blood-ves- 
sels, almost  the  appearance  of  a  thin  dissected  muscle.  This  is  the 
literygium  crassum.  We  can  lay  hold  of  both  these  varieties 
with  a  pair  of  forceps  without  much  difl&culty,  and  without  giving 
the  patieiat  any  pain,  and  raise  them,  not  merely  from  the  scleroti- 
ca, but  even  from  the  cornea.  We  can  do  this  with  greater  ease, 
when  the  patient  turns  his  eye  towards  the  side  whence  the  ptery- 
gium originates.  These  diseases  proceed  even  to  their  complete 
development  without  giving  any  pain,  and  even  almost  without 
an}^  disagreeable  feeling  in  the  eye.  Frequently  the  patient  re- 
ceives the  first  intimation  of  his  disease  from  some  other  person,  or 
from  examining  his  eyes  in  a  glass,  or  from  the  disease  gaining 
that  part  of  the  cornea  which  is  opposite  to  the  pupil,  and  thereby 
obscuring  vision. 

The  great  number  of  pterygia  which  have  their  basis  turned 
towards  the  nasal  angle  of  the  eye,  in  comparison  of  the  few  which 
arise  from  any  other  part  of  the  circumference  of  the  eyeball,  might 


I  163 

1  lead  us  perhaps  to  suppose  that  this  disease  consisted  in  an  elonga- 
I  ,ion  of  the  semihmar  fold  of  the  conjunctiva,  or  that  it  took  its 
mghi  from  the  caruticula  lachiymahs  ;  but  on  carefully  examining 
.1  pterygium,  it  will  appear  evident,  that  neither  the  membrana 
semilunaris,  nor  the  caruncula  lachrymalis,  takes  any  share  in  the 
I  jisease.  Besides,  we  have  the  occasional  occurrence  of  pterygium 
on  the  temporal,  and  even  on  the  superior  and  inferior  sides  of  the 
3ye.  Pterygium  on  both  sides  of  the  same  eye  had  occurred  only 
twice  to  Beer.  In  these  cases  they  met  in  the  centre  of  the  cornea, 
and  almost  entirely  deprived  the  patients  of  sight.  In  one  case 
Beer  found  three  pterygia  on  the  same  eye.  Mr.  Wardrop  men- 
tions having  seen  two  pterygia  on  each  eye  of  the  same  individual. 
Schmidt  gives  an  account  and  figure  of  an  extraordinary  pterygi- 
um, which  so  strongly  resembled  a  muscle  in  its  structure,  that  one 
might  have  almost  believed  that  the  rectus  superior  oculi  had  been 
misplaced.  It  took  its  origin  from  behind  the  upper  eyelid,  over 
the  eyeball  to  the  upper  edge  of  the  cornea,  exactly  in  the  form  of  a 
layer  of  muscular  fibres.  At  the  edge  of  the  cornea,  this  pterygium 
became  thicker  and  almost  tendinous,  and  opposite  to  the  pupil  it 
interwove  itself  with  the  cornea  in  the  same  manner  as  the  straight 
muscles  do  with  the  sclerotica.  This  pterygium  was  successfully 
removed  by  operation.* 

Causes.  Many  writers  have  considered  pterygium  as  a  conse- 
quence of  ophthalmia ;  but  this  opinion  appears  to  be  incorrect. 
It  is  true,  indeed,  that  tedious  or  neglected  ophthalmia,  or  ophthal- 
mia treated  with  many  relaxing  external  applications,  is  apt  to 
leave  the  conjunctiva  of  the  eyeball  so  loose,  that  on  every  motion 
of  the  eye,  it  falls  into  a  number  of  folds.  Such  cases,  however, 
never  appear  to  terminate  in  pterygium. 

Beer  was  led  to  believe,  from  a  careful  examination  of  the  evi- 
dent or  supposed  causes  of  the  numerous  cases  which  had  come 
under  his  observation,  that  pterygium  most  frequently  owed  its 
origin  to  the  influence  of  lime  or  fine  stone-dust  upon  the  conjunc- 
tiva, by  far  the  greater  number  of  patients  who  had  come  under 
his  care  with  this  complaint,  being  day-labourers,  who  are  ex- 
tremely exposed  to  this  cause. 

Prognosis.  Even  Avhen  a  pterygium  has  reached  its  complete 
development,  the  prognosis  is  always  favourable,  as  the  disease 
appears  to  be  entirely  of  a  local  nature.  The  duration  of  the  cure, 
indeed,  is  exceedingly  various.  Much  depends  on  whether  the 
operation,  which  is  the  quickest  and  most  certain  means  of  cure, 
be  immediately  determined  on  by  the  patient,  and  be  performed 
without  leaving  behind  any  part  of  the  pterygium,  or  whether  we 
content  ourselves  wiih  alternate  scarifications  and  stimulating  ap- 

*  Ophttialmologisclie  Bibliothek  von  Himly  unci  Schmidt.  Vol.  ii.  p.  57.  Jena, 
1803.  Mr.  Travers  has  represented  two  pter3rgia  occupying  the  upper  part  of  the 
eye.  One  of  these  extended  to  the  lower  margin  of  the  corneaj  and  was  of  sarcoma- 
tous density.     Synopsis  of  the  Diseases  of  the  Eye,  p.  424.     London,  1820. 


164 

plications,  till  the  pterygium  disappear  by  a  tedious  process  of 
organic  change  of  substance.  When  properly  treated,  no  trace  of 
the  disease  remains  ;  neither  over  the  sclerotica  nor  on  the  cornea. 
Treatment.  In  cases  of  pterygium  tenue,  not  yet  reaching  to 
the  cornea;  it  will  in  general  be  sufficient  to  lay  hold  of  the  ptery- 
gium with  a  small  pair  of  hooked  forceps,  and  then  divide  it  by 
two  or  three  vertical  scarifications.  After  this  it  shrinks  and  dis- 
appears. These  scarifications  may  perhaps  require  to  be  repeated. 
In  the  meantime,  the  part  may  be  touched  daily  with  the  vinous 
tincture  of  opium,  or  the  red  precipitate  salve. 

With  regard  to  pterygium  crassum,  the  best  plan  is  immediately 
to  remove  it  by  operation.  If  the  patient  refuses  to  submit  to  this, 
we  have  no  other  resource  than  the  employment  of  scarifications, 
as  in  the  former  case.  The  probability,  however,  is,  that  the  pa- 
tient will  tire  of  a  mode  of  cure  so  tedious ;  and  there  is  also  a 
danger,  that  the  pterygium,  instead  of  disappearing,  shall  become 
only  more  luxuriant  and  extensive.  If  the  patient  submits  to  the 
operation,  it  is  to  be  performed  in  the  following  manner.  The 
patier^t  being  laid  on  his  back  on  a  table,  the  assistant  takes  charge 
of  both  eyelids,  separating  them  so  as  fully  to  expose  the  eyeball. 
The  operator  lays  hold  of  the  pterygium  with  a  pair  of  hooked 
forceps,  near  its  base,  and  with  a  small  scalpel  divides  it  by  a  ver- 
tical incision.  If  the  pterygium  is  on  the  nasal  side  of  the  eye,  the 
breadth  of  at  least  a  line  is  to  be  left  between  the  incision  and  the 
semilunar  fold  of  the  conjunctiva.  The  forceps  are  now  to  be 
shifted  to  its  apex,  and  the  pterygium  cautiously  dissected  back 
from  the  cornea  and  sclerotica,  till  it  be  completely  removed.  If 
any  remains  of  it  appear  still  to  be  left,  they  must  be  laid  hold  of 
with  the  forceps,  and  snipped  off  with  the  scissors.  On  the  follow- 
ing day,  the  whole  surface  of  the  wound  is  found  in  a  state  of  su- 
perficial inflammation  and  suppuration.  To  this  there  quickly 
follows  the  reproduction  of  a  new  portion  of  conjunctiva,  and  the 
cure  is  generally  completed  in  twelve  or  fourteen  days. 

There  is  enumerated  a  third  variety  of  pterygium,  under  the 
name  of  'pterygium  ping-ue,  or  pinguecula.  This  appears  to 
have  its  seat  partly  in  the  conjunctiva  of  the  eyeball,  party  in  the 
cellular  membrane  connecting  the  conjunctiva  to  the  sclerotica. 
It  presents,  in  the  greater  number  of  cases,  a  small,  yellowish, 
well-defined  elevation,  situated  close  to  the  edge  of  the  cornea,  over 
which  it  very  rarely  advances,  and  never  to  such  a  degree  as  to 
interfere  with  vision.  Almost  constantly  it  is  situated  on  the  tem- 
poral side  of  the  eye.  Weller  assures  us,  that  this  little  tubercle 
contains  no  fat.  It  seldom  gives  rise  to  any  inconvenience.  If  it 
does,  it  is  to  be  laid  hold  of  with  the  hooked  forceps,  and  removed 
with  the  scissors. 

There  is  a  fourth  variety  of  pterygium  described  by  Mr.  Ward- 
rop,  under  the  name  of  fleshy  pterygium.  This  appears  by  his 
account,  to  originate  in  common  triangular  pterygium  improperly 


165 

treated  by  repeated  scarifications,  which,  instead  of  causing  its  dim- 
inution, make  it  grow  more  rapidly,  till  at  last  it  projects  from 
between  the  eyelids,  and  involves  the  semilunar  membrane  and  ca- 
runcula  lachrymalis.     It  is  to  be  removed  with  the  knife. 


I  SECTION    VI.— CONJUNCTIVA    ARIDA. 

!     In  this  rare  disease,  the  conjunctiva,  both  where  it  covers  the 
I  sclerotica,  and  on  the  surface  of  the  cornea,  loses  its  natural  slipperi- 
ness  and  moisture,  and  becomes  dry  and  shrivelled  hke  a  bit  of  cu- 
ticle which  has  been  detached  after  the  application  of  a  bUster.     In 
;  one  case  which  fell  under  my  observation,  and  which  did  not  ap- 
pear to  be  the  result  of  inflammation,  the  conjunctiva  corneee  only 
was  affected,  and  ,pr-esented  an  appearance  as  if  it  had  been  a  piece 
iof  silk  paper  laid  upon  the  surface  of  the  cornea.     It  is  to  this  dis- 
[ease  in  a  more  advanced  stage,  that  Mr.  Travels  refers,  when  he 
isays,  "I  have  seen  several  cases  of  the  conversion  of  the  conjunc- 
■  tiva  into  a  skin,  rugous  and  opaque,  knitting  the  hds  close  to  the 
globe,  so  as  to  obliterate  the  sinus  palpebrales."*     He  calls  it  cuti- 
i  cular  conjunctiva.     He  regards  it  as  one  of  the  sequelae  of  chronic 
[inflammation  of  the  conjunctiva,  and  as  immediately  depending  on 
[an  obliteration  of  the  lachrymal  ducts.     He  says,  that  in  such  cases 
there  is  no  secretion  of  tears. 


,;  SECTION  VII. — FUNGUS    OF    THE    CONJUNCTIVA. 

The  conjunctiva  is  subject  to  two  different  fungous  diseases,  both 

}•  of  them  attended  with  inflammation,  but  neither  of  them  sequelae 

1  of  the  specific  diseases  to  which  we  appropriate  the  name  of  ophthal- 

\  miae.     The  one  has  been  described  by  Beer,  under  the  name  of 

exophthaltmia  fungosa.t     Mr.  Allan,  in  the  third  volume  of  his 

Surgery.,  has  also  described  and  figured  this  disease.     The  other 

fungous  state  of  the  conjunctiva  I  have  not  found  described  by  any 

author. 

Symptoms.  The  first  variety  of  fungus  of  the  conjunctiva  is  of 
a  deep  red  colour,  inchning  to  livid  ;  it  affects  chiefly  the  conjunc- 
tiva covering  the  sclerotica,  over  which  it  is  elevated  in  irregulai* 
soft  smooth  masses ;  it  sometimes  rises  from  the  inside  of  the  lids, 
but  never  from  the  surface  of  the  cornea.  The  fungus  is  pressed, 
however,  by  the  ejj^elids,  over  the  edge  of  the  cornea,  and  sometimes 
to  such  a  degree,  as  to  hide  it  completely.  Unattended  by  pain, 
this  disease  goes  on  increasing,  till  it  projects  from  between  the  lids, 
and  prevents  them  from  closing.  If  neglected,  it  may  reach  to  a 
great  size,  and  is  liable  to  be  confounded  with  the  last  stage  of  spon- 
goid  tumour  of  the  eyeball.     Exposed  to  the  influence  of  the  air, 

*  Synopsis  of  the  Diseases  of  the  Eye,  p.  120.     London,  1820. 
t  Schwammichte  Exophtalmie ;  Sarcosis  bulbi. 


166 

the  secretion  from  the  surface  of  the  fungus  becomes  encrusted, 
while  the  irritation  of  the  foreign  substances  which  come  into  con- 
tact with  it,  renders  it  tender  and  apt  to  bleed.  For  a  time  the 
firmness  of  the  cornea  and  sclerotica  is  suflficient  to  resist  the  effects 
of  the  pressure  of  the  fungous  mass  by  which  they  are  surrounded, 
and  which  makes  way  for  itself  chiefly  by  projecting  and  dilating 
the  eyelids  ;  but  at  length  the  eyeball  begins  to  suffer  from  the 
pressure,  inflames,  bursts,  and  is  destroyed. 

The  second  variety  of  fungus  of  the  conjunctiva,  almost  of  gela- 
tinous consistence,  and  of  a  light  yellow  or  brownish  colour,  is  met 
with  chiefly  on  the  inside  of  the  lids,  especially  of  the  upper,  and  in 
the  superior  fold  of  the  conjunctiva.  It  sometimes  attains  a  very 
considerable  size,  and  although  soft,  and  destitute  of  red  vessels,  is 
apt  to  prove  destructive,  by  the  pressure  which  it  exercises  on  the 
eyeball.  Although  neither  of  these  fungous  affections  of  the  con- 
junctiva appears  to  be  strictly  malignant,  it  is  evident,  that  by  their 
mere  mechanical  effects,  they  may  prove  destructive  both  of  vision 
and  of  life.  Even  after  the  eyeball  has  been  destroyed  by  their 
pressure,  they  may  go  on  to  increase,  affect  the  bones  of  the  orbit, 
and  wear  out  the  patient  by  fever. 

Treatment.  In  the  early  stage  of  these  diseases,  leeches  to  the 
conjunctiva  would  probabh"  be  useful ;  and  benefit  might  perhaps, 
be  derived  from  the  application  of  the  vinous  tincture  of  opium,  or 
of  gentle  astringents  in  solution.  At  a  later  period,  escharotics  are 
naturally  thought  of,  especially  the  solid  nitras  argenti.  Should 
the  disease  still  advance,  extirpation  of  the  fungus  ought  not  to  be 
delayed  ;  and  in  both  varieties,  but  especially  in  the  second,  it  will 
be  found  of  much  advantage  to  commence  the  operation  by  sepa- 
rating the  eyelids  at  their  temporal  angle,  by  an  incision  carried  to- 
wards the  temple,  so  as  to  allow  the  whole  of  the  diseased  conjunc- 
tiva to  be  exposed  to  view.  The  extirpation  will  now  be  accom- 
phshed  with  comparative  ease,  by  means  of  the  hooked  forceps  and 
a  small  scalpel,  with  the  occasional  aid  of  the  scissors.  The  first 
variety  of  fungus,  when  we  attempt  to  dissect  it  from  the  sclerotica, 
bleeds  profusely,  so  that  the  assistant  must  be  prepared  to  clear 
away  the  blood  as  the  operator  proceeds,  by  injecting  cold  water 
over  the  eye.  After  the  whole  of  the  fungus  is  removed,  the  eye- 
lids, where  they  have  been  disunited,  are  to  be  brought  together 
with  a  stitch.  The  surface  exposed  by  the  removal  of  the  disease, 
will  in  a  day  or  two  be  covered  with  purulent  matter,  and  slowly 
become  invested  by  a  pseudo-conjunctiva.  Any  tendency  to  repj-o- 
duction  m.ust  be  prevented  by  the  use  of  the  nitras  argenti.  and 
sym-blepharon  guarded  against  by  frequent  motion  of  the  eye,  and 
the  introduction  of  a  little  mild  salve  into  the  folds  of  the  conjunc- 
tiva. 

When  fungus  of  the  conjunctiva  has  been  allowed  to  proceed  in 
its  course  till  the  eyeball,  by  its  pressure,  is  destroyed,  it  would  be 
difficult  to  remove  the  fungus  growth  by  itself,  and  it  is  quite  un-  > 


167 

necessary  to  attempt  to  do  so.  In  such  cases,  we  must  have  re- 
course to  extirpation  of  the  eyeball,  taking  care  also  to  remove  any 
part  of  the  fungus  arising  from  the  inside  of  the  eyeUds. 


SECTION    VIII. WARTS  OF  THE  CONJUNCTIVA. 

Warts,  red,  fleshy,  and  somewhat  granulated,  single,  or  in  clus- 
ters, are  met  with,  growing  from  every  part  of  the  conjunctiva,  not 
excepting  the  surface  of  the  cornea.  Mr.  Travers  compares  them 
to  the  warts  which  arise  from  the  inside  of  the  prepuce,  and  attri- 
butes their  origin  to  a  similar  cause,  namely,  irritation  from  a  dis- 
eased secretion.  I  have  already  had  occasion  to  refer  to  a  case,  in 
which  the  removal  of  a  small  wart  from  the  external  surface  of  the 
lower  eyelid,  was  followed  by  a  crop  of  warts  on  the  conjunctiva  of 
the  eyeball.  Mr.  Wardrop  has  described  and  figured  a  congenital 
warty  excrescence  of  the  corneal  conjunctiva.  He  mentions  that  it 
was  firm  and  immoveable,  with  a  rough  granulated  appearance 
externally,  and  from  its  brownish  colour,  did  not  appear  very  vas- 
cular. It  was  small  when  first  observed,  and  increased  in  size  in 
proportion  with  the  other  parts  of  the  body.*  Although  the  pro- 
gress of  these  excrescences  is  slow,  they  cause  considerable  irrita- 
tion and  inflammation  sometimes  extending  to  the  cornea,  and 
ought  therefore  to  be  immediately  removed  with  the  scissors.  Es- 
charotics  appear  to  have  scarcely  any  power  in  diminishing  their 
bulk,  although  they  may  perhaps  delay  their  progress. 


SECTION  IX. TUMOURS  OF    THE  CONJUNCTIVA. 

A  variety  of  tumours  take  their  origin  in  the  conjunctiva,  or  in 
I  the  cellular  membrane  which  connects  it  to  the  neighbouring  parts. 
Some  of  them  are  congenital,  others  arise  in  after-life. 

Mr.  Wardrop  has  described  and  figured  a  tumour,  about  the  bulk 
of  a  horse-bean,  of  which  a  small  part  seemed  to  grow  from  the. 
cornea,  while  the  rest  was  situated  on  the  sclerotica,  next  the  tem- 
poral angle  of  the  eye.  Its  surface  was  smooth,  and  covered  by 
the  conjunctiva.  Upwards  of  twelve  very  long  and  strong  hairs 
grew  from  its  middle,  passed  through  between  the  eyehds,  and 
hung  over  the  cheek.  The  patient,  at  this  time  upwards  of  50 
years  old,  remarked  that  these  hairs  did  not  appear  until  he  had 
advanced  to  his  sixteenth  year,  at  which  time  also  his  beard  grew.t 
Some  conjunctival  tumours  contain  a  watery  fluid,  and  disappear 
on  being  punctured.  Others  are  adipose,  steatoraatous,  or  even 
cartilaginous,  and  require  to  be  extirpated.  This,  in  most  cases, 
is  easily  effected,  for,  in  general,  they  are  but  loosely  attached  to 
I  the  sclerotica. 

I      *  Morbid  Anatomy  of  the  Human  Eye.    Vol.  i.  p.  32.    London,  1819.       t  Ibid. 


168 

Mr.  Travers  has  given  an  account  of  the  case  of  a  lady,  in 
whom  the  cornea  was  concealed  by  a  tumour,  of  a  dark  purple 
colour,  protruding  to  such  an  extent  between  the  ej^elids,  as  to  oc- 
casion great  inconvenience  and  deformity.  It  had  the  appearance 
of  being  disposed  in  lobes,  somewhat  resembling  a  bunch  of  cur- 
rants of  unequal  size.  Mr.  Travers  extirpated,  in  this  case,  the 
anterior  hemisphere  of  the  eyeball.  On  examination  of  the  tu- 
mour, the  cornea  and  sclerotica  proved  to  be  entire,  and  the  mor- 
bid growth,  lying  upon  and  adhering  to  the  cornea  and  a  small 
portion  of  the  sclerotica,  had  acquired  the  lobulated  appearance,  as 
if  by  degeneration  of  the  covering  conjunctiva,  for  delicate  white 
bands,  the  only  vestiges  of  this  membrane,  were  seen  intersecting 
the  lobules  at  irregular  distances,  in  the  form  of  septa.  The  sub- 
stance, on  dissection,  was  found  to  be  partly  firm,  partly  pulpy,  of 
a  dark  colour,  here  and  there  mottled  with  white,  and  measured  a 
quarter  of  an  inch  in  thickness  from  the  external  surface  of  the 
cornea.*  Had  Mr.  T.  been  aware  of  the  external  seat  of  this  tu- 
mour, perhaps  he  might  have  endeavoured  to  extirpate  it,  without 
sacrificing  any  part  of  the  eyeball.  In  the  explanation  of  the  two 
figures  which  he  has  given  of  the  tumour,  he  tells  us  that  when 
he  first  saw  the  case,  he  formed  the  idea  that  it  was  a  fungus 
originating  from  the  iris  or  choroid,  consequent  to  a  slough  of  the 
cornea.  The  patient  recovered  quickly  from  the  operation,  and 
the  remaining  part  of  the  eyeball  collapsed.  From  the  dark  col- 
our, and  partly  pulpy  consistence  of  the  morbid  growth,  may  we 
not  suspect  it  to  have  been  of  the  nature  of  melanosis  ?  Mr.  T. 
mentions  that  the  surface  of  the  cornea  was  rough,  and  had  a 
brownish  tint,  as  if  beginning  to  degenerate  into  the  morbid  mass 
which  lay  above  it.  The  figure  which  Mr.  T.  has  given  of  the 
external  appearance  of  the  tumour  is  very  simiiiar  to  the  eye  of  a 
gentleman,  by  whom  I  was  consulted  about  two  years  ago,  and 
who  submitted  by  my  advice  to  have  the  anterior  half  of  the  eye- 
ball extirpated,  as  in  Mr.  T.'s  case.  Dr.  Monteath  being  consulted, 
approved  of  and  performed  the  proposed  operation :  but  on  exam- 
ining the  portion  of  ihe  eye  which  was  removed,  we  found  the 
melanotic  degeneration  to  occup)^  the  whole  place  of  the  vitreous 
humour,  so  that  the  rest  of  the  eye  was  immediately  extirpated. 
The  case  did  well,  and  I  have  heard  of  no  return  of  the  disease. 

*  Synopsis  of  the  Diseases  of  the  EyCj  p.  102  and  394.     London,  1820. 


169 


CHAPTER  V. 

DISEASES  OF  THE  SEMILUNAR  MEMBRANE,  AND  CARUN- 
CULA  LACHRYMALIS. 

SECTION  I. INFLAMMATION    OF    THE    SEMILUNAR    MEMBRANE 

AND  CARUNCULA  LACHRYMALIS. 

'  Symptoms.     The  semilunar  membrane  and  caruncula  lachryma- 
\  lis,  when  inflamed,  become  much  enlarged,  of  a  bright  red  colour, 
\  and  affected  with  considerable  pain,  especially   when  the  lids  are 
'  moved.     The  inflammation  extends  in  some  degree  to  the  con- 
,  junctiva,  of  which,  indeed,  the  semilunar  membrane  is  a  portion, 
and   by   which  the  caruncula  is  invested.     The  sensation  as  if 
some  foreign  body  was  lodged  in  the  inner  angle  of  the  eye  at- 
tends this  disease,  the  absorption  of  the  tears  is  obstructed,  and  an 
increased  secretion  of  mucus,  sometimes    puriform,  flows  from  the 
'  Meibomian  follicles,  conjunctiva,  and  caruncula.     In  some  cases, 
suppuration  takes  place  in  the  substance  of  the  caruncula,  the  red- 
,  ness  and  swelling  increasing  for  a  time,  till  matter  forms,  when  the 
'.  swelling  points,  breaks,  and  discharges  itself.      Fungous  excres- 
I  cences  are  apt  to  follow,   and  sometimes  a  permanent  distortion  of 
'  the  caruncula  ;  while  in  other  instances,  it  is  entirely  destroyed  by 
the  suppuration. 

Causes.     The  influence  of  cold  is  the  most   frequent  cause  of 

this  inflammation.     I  had  a  very  distinct  instance  of  this,  in  a 

.  patient  who  caught  cold  while  i-ecovering  from   dysentery.     Slight 

;  injuries  may  also  induce  this   disease.     Foreign  bodies  lodging  be- 

,  hind  the  semilunar  membrane,   or  so  fixed   as  to  irritate  the  car- 

I  uncula,  may  also  be  the  cause.     Dr.  Monteath  mentions  his  having 

seen  tViis  disease  in  two  instances,  produced  by  a  loose  eyelash,  the 

root  or  thick  end  of  v/hich  had  fairly  entered  the  upper  punctura 

\  and  lachrymal  canal.     Its  other  extremity  consequently  pointed 

^  downwards  to  the  caruncula,   which  it  constantly  irritated.     The 

■  troublesome  irritation  which  had  been  excited  in  both  instances, 

immediately  subsided  on  removing  the  eyelash  from  the  lachrymal 

canal. 

Treatment.  The  removal  of  the  cause,  when  that  is  known 
and  removeable,  as  in  the  instance  just  quoted  ;  bathing  the  parts 
frequently  with  tepid  w^ater ;  touching  them  once  a-day  with  the 
lunar  caustic  solution  ;  and  the  use  of  laxatives,  make  up  the  gen- 
eral treatment.  Should  the  swelling  go  on  increasing,  a  leech 
:  may  with  propriety  be  applied  to  the  inflamed  caruncula ;  and  if 
suppuration  threatens,  a  bread  and  water  poultice,  in  a  thin  linen 
bag,  is  to  be  laid  over  the  inner  angle  of  the  eye.  The  suppurated 
caruncula  is  to  be  opened  with  the  lancet.  Should  it  threaten- to 
throw  out  fungous  granulations,  we  must  endeavor  to  repress  them 
22 


170 

by  the  vinous  tincture  of  opium,  or  the  appHcation  of  sulphas  cupri^ 
or  nitras  argenti.  If  these  means  are  insufficient,  the  fungus  must 
be  removed  with  the  scissors. 


SECTION    II. ENCANTHIS. 

This  term  is  applied  to  a  chronic  enlargement  of  the  caruncula 
lachrymalis  and  semilunar  membrane,  but  especially  of  the  former. 
Encanthis  benigna  has  been  distinguished  from  encanthis  mahgna ; 
the  former  a  mere  fungus  state  of  the  parts,  the  effect  of  simple 
mflammation,  and  disappearing  under  the  use  of  the  remedies 
already  enumerated ;  the  latter  a  scirrhous  affection  of  the  glan- 
dular substance  of  the  caruncula,  degenerating,  if  neglected,  into 
cancerous  ulceration. 

SymiHonis.  In  scirrhous  encanthis,  the  caruncula  presents  the 
appearance  of  a  very  hard,  irregular  swelling.  It  involves  the 
semilunar  fold,  and  extends  to  the  conjunctiva  lining  the  lids.  It 
is  at  first  of  a  uniform  red  colour,  but  after  it  has  attained  a  con- 
siderable bulk  beyond  the  natural  size  of  the  caruncula,  it  becomes 
here  and  there  of  a  whitish  colour,  with  varicose  vessels  ramifying 
over  its  surface.  It  is  the  seat  of  lancinating  pain.  It  impedes, 
by  its  size,  the  functions  of  the  eyelids  and  excreting  lachrymal 
passages.  The  hairs  growing  from  it  become  much  stronger  than 
natural.  Its  surface  is  easily  excited  to  bleed.  At  last  it  ulcerates, 
the  edges  of  the  sore  become  everted,  and  the  discharge  is  thin  and 
acrid,  irritating  and  excoriating  the  neighboring  parts.  If  allowed 
stUl  to  proceed  in  its  course,  the  cancerous  ulceration  spreads  to  the 
Uds,  lays  open  the  lachrymal  passages,  attacks  even  the  eyeball, 
and  in  fact  runs  a  course  similar  to  that  of  cancer  of  the  lids,  as 
ah-eady  described. 

Treatment.  The  scirrhous  encanthis  requires  to  be  extirpated. 
For  this  purpose  a  curved  needle,  armed  with  a  linen  thread,  is  to 
be  passed  through  the  tumour,  by  means  of  which  it  may  be  drawn 
out  from  the  neighbouring  parts,  while,  with  a  small  scalpel  or  the 
scissorS;  it  is  completely  separated  from  its  connexions.  It  is  proba- 
ble, that  the  removal  of  the  caruncula  and  semilunar  fold,  will  be 
followed  by  incurable  stillicidium  lachrymarum,  but  of  course  this 
is  not  to  be  compared  with  the  dangers  attending  a  scirrhous^  or 
cancerous  affection  of  these  parts,  if  left  to  itself. 


171 


CHAPTER  VI. 

DISEASES  OF  THE  EXCRETING  LACHRYMAL  ORGANS. 

SECTION    I.^INJURIES    OF    THE    EXCRETING    LA.CHRYMAL 

ORGANS. 

1.  Injuries  of  the  Lachrymal  Canals. 

If  the  canals  which  lead  from  the  puncta  lachrymalia  to  the  lach- 
rymal sac  are  wounded,  the  important  question  is,  how  far  the 
eyelids  are  likely  to  be  distorted,  and  the  integrity  of  either  of  the 
canals  destroyed,  by  the  cicatrice  which  must  follow,  or  by  the  sup- 
purative inflammation  which  in  every  case  is  to  be  dreaded.  When 
the  wound  has  been  occasioned  by  a  clean  cutting  instrument,  we 
may  hope  for  a  cure,  without  either  distortion  of  the  eyehds  or 
permanent  interruption  of  the  function  of  the  canals.  When  the 
part  is  torn  or  bruised,  it  will  probably  be  completely  destroyed  by 
the  consequent  suppuration ;  and  if  both  canals  are  included  in 
the  injury,  an  irremediable  stillicidium,  or  discharge  of  tears  and 
mucus  from  the  nasal  angle  of  the  eye,  is  the  unavoidable  con- 
sequence. 

In  lacerated  wounds,  then,  our  prognosis  must  be  doubtful. 
Yet  even  such  wounds  are  sometimes  happily  cured.  Schmidt 
relates  the  case  of  a  person  who  in  a  game  at  blindman's  buff,  was 
laid  hold  of  by  the  finger  of  one  of  the  party,  exactly  in  the  nasal 
angle  of  the  eye,  and  had  the  under  eyelid  torn  away  to  the  length 
of  half  an  inch  from  the  upper.  Mohrenheim,  who  happened  to 
be  in  the  company,  pronounced  an  unfavourable  prognosis ;  but 
by  Schmidt's  care  the  case  was  cured  in  eight  days,  without  the 
■slightest  stillicidium  or  ectropium. 

The  indications  in  cases  of  wounds  of  the  canals,  are,  to  bring 
the  separated  parts  into  apposition,  and  then  to  keep  them  so. 
This  can  scarcely  be  effected  without  the  introduction  of  a  stitch. 
Slips  of  plaster  are  then  to  be  applied  by  one  end  to  the  cheek  or 
to  the  temple,  thence  to  pass  over  the  wound,  and  be  fixed  by  the 
other  end  to  the  forehead  or  to  the  nose :  for  if  they  be  short,  and 
applied  merely  over  the  wound,  they  will  soon  be  moistened  and 
displaced  by  the  tears.  A  compress  and  bandage  are  necessary ; 
and  the  patient  must  be  careful  to  keep  the  eyes  at  rest  till  the 
wound  is  perfectly  united. 

If  the  wounded  canal  does  not  unite,  but  each  end  of  the  division 
cicatrizes  separately,  little  is  to  be  hoped  from  making  raw  the 
edges  of  the  wound,  and  again  trying  to  unite  them  with  greater 
■accuracy. 

2.  Injuries  of  the  Lachrymal  Sac. 

The  lachrymal  sac  is  pretty  well  protected  from  injury.     It  is 


172 

occasionally,  however,  laid   open   both  in  incised  and  lacerated 

■u-ounds.  These  must  be  treated  with  care,  lest  they  degenerate 
into  fistulee.  Schmidt  mentions  a  case  in  which  a  penetrating 
wound  of  the  sac  ended  in  this  way.  Should  the  opening  into 
the  sac,  having  contracted  to  a  small  size,  threaten  to  cicatrize  over 
its  edges,  they  must  be  touched  with  the  nitras  argenti,  and  brought 
to  heal  slowly  by  gi-anulation. 

3,  Injuries  of  the  Nasal  Duct. 

The  duct  itself  is  completely  secured  from  all  immediate  injury ; 
but  the  osseous  canal,  through  which  it  passes,  is  sometimes  frac- 
tured, and  its  sides  pressed  together,  by  severe  blows  on  the  face. 
I  have  seen  this  follow  a  kick  from  a  horse,  received  on  the  side 
of  the  nose.  The  consequence  was  complete  obliteration  of  the 
passage  for  the  tears. 


SECTION    II. ACUTE    INFLAMMATION    OF    THE    EXCRETING 

LACHRYMAL    ORGANS. 

Symptoms.     With  a  feeling  of  obtuse,  deep-seated  pain,  extend- 
ing to  the  nose  and  to  the  eye,  a  circumscribed  swelling  appears 
in  the  situation  of  the  lachrymal  sac,   hard,   very  sensible  to  the 
touch,   and   affected  with  stinging  pain   whenever  it  is  pressed. 
This  swelling  becomes  gradually  red,  at  last  extremely  red,  and  | 
then  the  least  touch  is  insupportable.     The  papillee  are  shrunk,  i 
the  puncta  scarcely  visible,  the  absorption   and  conveyance  of  the  | 
tears  into  the  lachrymal  sac,  and  through  the  nasal  duct  into  the   I 
nose,  completely  stopped,  and  a  stilhcidium  lachrymarum  is  present.   | 
The  nostril  on  the  affected  side  is  at  first  uncommonly  moist ;  but  | 
it  soon  becomes  dry,  the  inflammation  extending  to  the  mucous  I 
membrane  of  the  nostril.     The  inflammation  affects  the  caruncula  ' 
lachrymalis,  and  the  conjunctiva,  spreading  also  to  the  orbicularis  i 
palpebrarum,  and  to  the  integuments  of  the  lower  eyelid.     The 
redness  about  the  nasal  angle  of  the  eye,  extending  with  some 
degree  of  sweUing  even  to  the  cheek,  gives  to  the  parts  when 
viewed  at  a  distance  an  appearance  as  if  the  integuments  were 
attacked  b)^  erysipelas  ;  but  on  a  nearer  examination,  the  pecuUar 
redness,  and  all  the  other  characteristics  of  phlegmonous  inflam- 
mation, are  recognised ;  and  in  the  midst  of  the  diffused  discolora- 
tion and  tumefaction,  the  circumscribed  swelling  of  the  lachrymal 
sac  is  evident  not  merely  to  the  touch,  but  even  to  view. 

The  primary  and  chief  seat  of  this  disease  is  the  mucous  mem- 
brane of  the  whole  of  the  excreting  parts  of  the  lachrymal  organs. 
When  the  pure  inflammation  has  reached  its  highest  degree,  and 
is  about  to  pass  into  the  suppurative  stage,  this  mucous  membrane 
begins  to  be  exceedingly  tumefied.  The  tumefaction  of  the  parietes 
of  the  lachrymal  canals  and  of  the  nasal  duct  is  very  soon  so  great, 


173 

tliat  these  tubes  cease  to  be  pervious.  The  same  tumefaction  ex- 
tends also  to  the  parietes  of  the  sac.  The  nasal  duct  being  inclosed 
in  an  osseous  canal  cannot  become  tumefied  by  inflammation,  and 
at  the  same  time  leave  a  free  passage  to  the  tears.  The  anteriot 
side  of  the  sac,  on  the  other  hand,  being  covered  only  by  soft  parts, 
is  gradually  distended,  so  as  to  form  the  tumour  already  mentioned, 
and  which  l^ecomes  much  more  considerable  when  the  disease  is  so 
far  advanced  that  the  mucus  secreted  is  of  an  inordinate  quantity 
and  puriform.  The  pressure  from  within  the  sac  produces  pro- 
gressive absorption,  so  that  the  matter  comes  gradually  towards  the 
surface,  while  the  thickening  of  the  mucous  membrane  behind 
serves  to  secure  the  deeper-seated  parts.  Mr.  Hunter  has  repeated- 
ly referred  to  the  matter  within  the  sac  not  following  the  shortest 
way,  which  would  be  directly  into  the  nose,  but  coming  to  the  ex- 
ternal surface,  as  an  illustration  of  the  instinctive  provision  which 
exists  in  the  body  for  bringing  extraneous  and  morbid  substances 
to  the  skin  for  their  exit.*  Occasionally,  hovi^ever,  the  means  of 
protection  becomes  a  cause  of  future  evil,  for  there  sometimes  takes 
place  such  a  change  in  the  texture  of  the  parietes  of  the  canals,  sac, 
and  duct,  that  they  can  scarcely  ever  return  to  their  natural  state. 
The  thickening  of  their  mucous  and  fibrous  coats  continues  in  this 
case  after  the  inflammatory  disease  has  run  its  course;  and  when 
the  inflammation  is  violent,  this  thickening  is  sometimes  so  great 
as  to  produce  the  complete  and  incurable  obliteration  of  the  excre- 
tory lachrymal  apparatus.  This  permanent  obliteration  appears  to 
depend  upon  an  effusion  of  coagulable  lymph  into  the  substance  of 
the  mucous  and  fibrous  coats,  and  into  the  cellular  substance  by 
which  these  are  connected  and  surrounded.  Stricture  of  a  portion 
of  one  or  both  of  the  canals,  or  of  the  duct,  is  produced  in  the  same 
manner. 

Weakly  patients,  towards  the  end  of  the  inflammatory  stage, 
•complain  of  headach,  and  present  the  other  symptoms  of  febrile 
disturbance  of  the  constitution.  The  pain  of  the  parts  primarily 
affected  is  often  very  severe,  in  consequence,  no  doubt,  of  the  un- 
yielding nature  of  the  surrounding  structures.  The  "whole  head 
suffers,  and  the  fever  is  occasionally  attended  with  delirium. 

As  happens  with  all  mucous  membranes  in  a  state  of  inflamma- 
tion, a  very  abundant  morbid  secretion  of  mucus  takes  place  at  the 
transition  of  the  first  into  the  second  stage.  This  fluid  collects  in 
such  a  quantity  within  the  lachrymal  sac,  that  the  tumour  is 
strikingly  increased  in  size,  and  is  felt  distinctly  to  fluctuate.  The 
accumulated  mucus  cannot  escape  in  any  considerable  quantity 
from  the  sac  into  the  nose,  on  account  of  the  swollen  state  of  the 
hning  membrane  of  the  nasal  duct,  or  it  may  be  on  account  of  its 
actual  obhteration,  or  at  least  stricture.  From  the  same  causes  the 
accumulated    mucus   cannot   be   regurgitated    by  the    lachrymal 

*  Hunter  on  the  Blood,  Inflammation,  and  Gun-shot  Wounds,   Vol.  ii.  pp.  298, 
;:  331,  8vo.    London,  1802. 


174 

canals.  Besides,  though  the  tears  are  more  plentifully  secreted 
during  this  disease  than  during  health,  they  are  not  absorbed  and 
conveyed  into  the  sac,  where  they  might  have  the  effect  of  diluting 
this  morbid  mucous  secretion.  With  the  commencement  of  the 
suppurative  stage,  there  is  also  a  morbid  secretion  from  the  carun- 
cula  lachrymalis  and  the  mucous  membrane  of  the  nostril. 

The  tumour  of  the  lachrymal  sac  increases  more  and  more,  the 
redness  becomes  darker,  the  skin  over  the  tumour  more  and  more 
shining,  the  fluctuation  more  distinct,  and  the  morbid  secretion  is 
now  completely  puriform.  The  sac  and  the  parts  by  which  it  is 
covered,  altered  by  inflammation,  are  incapable  of  any  further  dis- 
tention. The  skin  covering  the  sac  sometimes  mortifies  and 
sloughs  ;  but  more  commonly  in  the  middle  of  the  swelling,  a  yel- 
lowish, soft  point  is  observed,  which  soon  gives  way.  The  collec- 
tion of  puriform  mucus,  left  to  itself,  works  a  passage  through  the 
orbicularis  palpebrarum,  and  through  the  integuments  ;  but  by  this 
opening,  the  thinner  parts  merely  of  the  puriform  secretion  will  be 
discliarged,  and  the  tumour  will,  at  least  for  a  considerable  time,  be 
but  inconsiderably  diminished. 

By  and  by  w^e  observe,  when  we  press  upon  the  superior  part 
of  the  sac,  that  not  merely  puriform  mucus  is  discharged  by  the 
opening,  but  occasionally  also  a  quantity  of  pure  tears,  a  proof  that 
the  conveyance  of  the  tears  into  the  sac  is  re-estabhshed. 

For  some  time  after  the  process  of  suppuration  has  ended,  there 
continues  from  the  mucous  membrane  of  the  €ac  a  morbid  secre- 
tion, opaque  and  still  somewhat  like  pus.  It  occasionally  accumu- 
lates so  as  to  push  out  the  little  plug  of  lint,  which  may  have  been 
placed  in  the  opening  of  the  sac. 

At  length  this  morbid  secretion  also  ceases  in  its  turn,  and  the 
proper  mucus  comes  to  be  secreted  in  natural  quantity.  It  is  in 
general  transparent,  although  for  a  while  it  presents  occasional 
streaks  of  a  white  colour.  These  at  last  entirely  disappear,  and 
the  mucus  becomes  thinner  in  consequence  of  a  due  intermixture 
of  tears.  The  opening  of  the  sac  now  heals  either  spontaneously 
or  by  the  assistance  of  art.  Most  frequently  it  begins  with  con- 
tracting to  an  almost  capillar}^  aperture,  by  which,  if  the  nasal 
duct  has  not  returned  to  its  natural  dilatation,  tears  and  mucus  are 
discharged.  Should  this  capillary  opening  close,  and  the  duct  still 
continue  impervious,  the  patient  is  obliged  several  times  in  the 
day  to  press  upon  the  sac,  that  the  mucus  and  tears  which  it  con- 
tains may  be  discharged  through  the  lachrymal  canals. 

Causes.  Among  the  causes  of  this  disease,  exposure  to  cold, 
and  contusions  on  the  side  of  the  nose,  are  those  most  frequently 
noticed  by  patients.  Beer  mentions  the  case  of  a  child  of  four 
years  old,  in  w4iom  it  arose  from  the  irritation  of  a  large  pea  which 
had  been  thrust  so  deep  into  one  of  the  nostrils  that  it  was  with 
difl&culty  extracted.*     In  every  instance,  this  is  a  sudden  and  rapid 

*  Praktische  Beobachtungen  Uber  Augenkrankheiten,  p.  32.     Wien,  1791. 


175 

'  disease,  unpreceded  by  any  signs  of  obstruction  of  the  lachrymal 
passages,  and  occurring,  in  general,  in  healthy  individuals. 

Prognosis.  The  prognosis  in  acute  inflammation  of  the  lach- 
rymal sac  is,  in  every  period  of  its  course,  more  favourable  than  in 
the  chronic  disease,  which  has  probably  been  long  preceded  by 
imperfect  transmission  of  the  tears  into  the  nose,  and  occurs  in 
persons  vi^hose  constitution  is  in  a  state  of  weakness  and  derange- 
ment. 

When  this  disease  arises  from  no  considerable  injury  of  the  sac, 
but  from  some  slight,  perhaps  unknown  cause,  the  prognosis  is 
jVery  favourable  during  the  first  stage  ;  that  is,  before  the  secretion 
of  puriform  mucus  has  commenced.  If  the  disease  has  reached 
the  suppurative  stage,  we  have  to  contend  indeed  with  a  blenor- 
rhoea,  or  morbid  secretion  and  accumulation  of  mucus;  but  under 
proper  treatment  these  symptoms  will  readily  disappear.  When 
the  inflammation  is  from  the  beginning  severe,  or  the  case  has 
been  neglected  or  mistreated,  the  nasal  duct  and  lachrymal  canals 
run  the  risk  of  obliteration ;  and  it  is  to  be  accounted  fortunate  if 
the  duct  is  obliterated  at  its  lower  extremity  only,  or  the  canals 
merely  at  their  termination  in  the  sac.  Not  unfrequently  the 
whole  length  of  the  duct  is  converted  into  a  ligamentous,  almost 
cartilaginous  substance,  which  baifles  every  attempt  to  restore  its 
natural  caliber  ;  and  in  this  case,  both  the  lachrymal  canals  and 
the  sac  itself  usually  become  impervious.  The  possibility  of  such 
events  must  be  borne  in  mind,  when  we  are  called  in  even  during 
the  first  stage. 

The  prognosis  during  the  second  or  suppurative  stage  is  extreme- 
ly dubious.  No  surgeon,  however  great  his  experience,  can  know 
how  far  during  the  first  stage,  the  permeability  of  the  canals  has 
been  affected  ;  nor  can  heat  this  period  attempt  to  ascertain  by 
probes  the  state  of  the  parts,  without  exposing  them  to  essential 
injury.  If  we  are  called  in  just  as  the  suppuration  has  fairly 
commenced,  our  treatment  may  perhaps  moderate  that  process ; 
and,  at  least,  we  have  it  in  our  power  to  open  the  sac  at  the  proper 
time  and  in  the  proper  place.  If  we  are  later,  we  probably  have 
a  fistula  to  contend  with. 

Treatment.  It  is  by  combating  the  inflammation  that  we  are 
to  cure  this  disease,  and  not  by  attacking  merely  one  or  even  seve- 
ral of  the  symptoms.  Dilatation,  for  instance,  by  the  introduction 
of  probes  through  the  canals,  into  the  sac,  and  even  into  the  nose, 
would  only  be  subjecting  the  inflamed  parts  to  a  new  cause  of  irri- 
tation, and  might  thus  produce  effects  which  would  render  a  com- 
plete cure  difficult  if  not  impossible. 

The  method  of  treatment  before  the  process  of  suppuration  has 
commenced,  is  sufficiently  simple.  In  mild  cases,  it  consists  in  ob- 
serving the  antiphlogistic  regimen,  and  in  carefully  applying  to  the 
inflamed  parts  a  piece  of  folded  linen,  moistened  with  cold  or  tepid 
water,  or  with  a  diluted  solution  of  acetate  of  lead.    In  severe  cases, 


176 

bleeding  at  the  arm,  immediately  followed  by  the  application  ol 
leeches  in  the  neighbourhood  of  the  inflamed  parts,  ought  to  be  em- 
ployed. Leeches  over  the  swelling  will  be  found  particularly  use- 
ful. Should  any  constitutional  symptoms  supervene  towards  the 
termination  of  this  stage,  the  bowels  are  to  be  freely  opened,  and 
a  gentle  degree  of  perspiration  maintained  by  the  use  of  some  o] 
the  common  diaphoretics.  Our  object  here  is  to  arrest  the  process 
of  inflammation,  and  to  prevent  it  from  passing  into  suppuration,  i 

Where  this  is  impossible,  and  the  symptoms  declare  that  the  pro- 
cess of  suppuration  is  commencing,  our  debilitating  plan  of  treat- 
ment should  immediately  cease.  If  it  be  continued,  the  mucous 
membrane,  which  is  the  seat  of  the  inflammation,  swells  much  mon 
than  it  would  have  otherwise  done,  and  the  consequent  blenorrhoef 
continues  so  stubbornly  that  it  threatens  sometimes  to  be  inveterate 
and  incurable.  The  cold  lotion  should  now  give  way  to  a  warn 
emollient  poultice. 

Should  our  hopes  of  checking  the  disease  be  still  disappointed 
and  the  secretion  of  puriform  mucus  go  on  augmenting,  the  sa< 
must  be  opened  with  the  knife,  as  soon  as  it  is  so  overfilled  and  th(, 
parts  which  cover  it  so  far  disorganized  that  the  middle  of  the  tu 
mour  becomes  soft  and  yellowish,  pointing  like  an  abscess.  Wt 
make  our  incision  in  the  direction  of  the  longer  diam.eter  of  the  tu 
mour,  and  as  we  withdraw  the  lancet,  enlarge  the  opening  down 
wards  through  the  integuments,  that  the  matter  may  have  a  fre< 
exit.  We  may  now  introduce  a  common  silver  probe  into  the  sac 
and  direct  it  downwards  into  the  nasal  duct.  We  shall  almost  al 
ways  find  that  it  descends  freely  into  the  nostril.  With  tepid  wa 
ter  and  the  lachrymal  syringe,  we  next  wash  out  the  parts,  and  thi 
is  to  be  repeated  daily.  A  common  poultice  is  now  to  be  applied 
inclosed  in  a  thin  linen  bag,  and  after  the  opening  has  continued  fo 
several  days,  and  the  matter  has  been  freely  evacuated,  if  the  sa^ 
should  continue  hard,  a  warm  poultice  of  cicuta  leaves  with  cam 
phor  is  recommended  for  discussing  the  induration.  A  bit  of  leatb 
er  spread  with  mei'curial  plaster  is  also  found  useful  for  this  jjurpose 

As  soon  as  the  object  of  this  application  is  gained,  the  wound  i 
to  be  filled  with  a  small  quantity  of  soft  lint,  dipped  in  the  vinou 
tincture  of  opium,  and  the  whole  covered  with  a  piece  of  adhesiv 
plaster.  Under  this  treatment  the  process  of  suppuration  dimin 
ishes,  and  the  matter  discharged  begins  to  lose  more  and  more  th 
character  of  pus,  and  to  approach  to  that  of  mucus. 

Should  this  unnatural  secretion  threaten  to  become  habitual,  th 
small  quantity  of  lint  introduced  into  the  wound  is  to  be  covere 
with  red  j)recipitate  ointment.  With  this  the  wound  is  to  be  dresse 
daily  ;  but  after  removing  the  old  dressing  and  the  mucus  whicl 
may  have  accumulated,  a  little  of  a  weak  solution  of  the  sulphat 
of  zinc  (gr.  ii.  §  i.)  made  lukewarm,  is  to  be  dropped  into  the  na 
sal  angle  of  the  eye,  and  some  of  the  same  solution  is  to  be  inject 
ed  through  the  wound  into  the  sac. 


177 

At  this  period,  if  the  treatment  has  been  properly  conducted,  we 
most  frequently  find  that  the  lachrymal  canals  and  the  nasal  duct 
have  of  themselves  become  permeable,  the  secretion  of  mucus  na- 
tural in  quantity  and  quality,  and  mixed  duly  with  the  fluids  ab- 
sorbed from  the  lacus  lachrymarum.  We  therefore  proceed  to  ap- 
ply such  dressings  to  the  opening  of  the  sac  as  may  induce  it  to 
close.  If  we  have  any  doubt  of  the  complete  permeabihty  of  the 
lachrymal  canals  and  nasal  duct,  we  have  recourse  to  that  exami- 
nation of  the  parts  which  I  shall  describe  in  the  ninth  and  tenth 
sections  of  this  chapter. 


SECTION    III. CHRONIC    BLEN6RRHCEA    OF    THE    EXCRETING 

LACHRYMAL  ORGANS. 

This  is  by  far  the  most  common  disease  to  which  the  excreting 
lachrymal  organs  are  subject. 

SyTnptoms.  The  inflammation  with  which  this  disease  com- 
mences, is  very  seldom  considerable.  In  scrofulous  patients  espe- 
cially, the  purely  inflammatory  stage  is  not  unfrequently  completely^ 
overlooked,  and  no  advice  is  asked  or  treatment  thought  of,  till 
mucus  has  accumulated  to  such  a  degree  as  considerably  to  distend 
the  lachrymal  sac.  The  first  thing  which,  in  general,  attracts  the 
patient's  attention,  is  weakness  of  the  eye,  from  the  tears  gathering 
at  the  internal  canthus.  When  he  begins  to  read,  or  look  earnestly 
at  any  minute  object,  he  finds  a  tear  ready  to  drop  over  on  the 
cheek ;  and  to  relieve  himself  of  this  inconvenience,  he  puts  up  his 
finger  upon  the  sac,  and  forces  its  contents  down  into  the  nose. 
He  goes  on  in  this  way  perhaps  for  months  or  years.  But  after  a 
time,  he  finds  that  the  tears  no  longer  go  down  into  the  nose,  when 
he  presses  at  the  inner  corner  of  the  eye,  as  they  did  before  ;  but 
regurgitate  by  the  puncta  lachrymalia.  This,  however,  still  affords 
rehef,  and  the  patient  may  persist  in  the  practice  for  a  great  length 
of  time.  If  he  gets  alarmed  about  the  complaint,  and  applies  at 
this  stage  of  it  for  advice,  we  find  that  when  we  press  upon  the  tu- 
mour formed  by  the  distended  sac,  a  quantity  of  puriform  mucus 
wells  out  through  the  puncta  and  overflows  the  eye ;  for  so  far  are 
the  canals  from  being  obstructed,  that  except  when  there  is  a  smart 
renewal  of  inflammation,  they  even  absorb  and  convey  the  tears 
into  the  sac.  Rarely,  however,  at  this  stage  of  the  complaint,  can 
our  pressure  empty  the  contents  of  the  sac  through  the  nasal  duct, 
as  its  permeability  is  for  the  most  part  suspended  by  general  tume- 
faction of  its  mucous  membrane,  or  by  stricture  at  some  particular 
points  ;  and  hence  also  the  patient  almost  constantly  complains  of 
dryness  in  the  nostril.  The  evacuation  of  the  contents  of  the  sac, 
whether  by  the  duct  or  by  the  canals,  produces  but  an  inconsidera- 
ble diminution  in  the  tumour. 

The  degree  of  inflammation  which  exists  in  different  cases  of 
23 


178 

chronic  blenoiThcea,  and  even  in  the  same  case  at  different  times, 
is  very  various.  Sometimes  we  find  the  integuments  perfectly  free 
from  discoloration,  and  meiely  elevated  by  the  distended  sac.  At 
other  times,  they  are  severely  inflamed,  exquisitely  tender  to  the 
touch,  thinned  by  the  pressure  of  the  puriform  mucus,  and  ready 
to  give  way. 

The  extent,  too,  of  the  inflammation  is  various.  The  lining 
membrane  of  the  sac  is  its  chief  seat.  In  many  cases,  we  have 
reason  to  suspect  that  the  whole  excretory  passages  are  affected  ; 
while  in  others  it  is  evident  that  one  or  other  of  the  lachrymal  canals 
only  is  the  source  of  the  blenorrhoeal  discharge.  I  had  under  my 
care  a  lady  in  whom  the  upper  lachrymal  canal  only  seemed  to  be 
affected.  The  surgeon  in  the  country,  under  whose  care  she  had 
been,  had  treated  the  case  as  one  of  inflammation  of  the  conjunc- 
tiva :  there  was  no  lachrymal  tumour :  the  matter,  oozing  from 
the  upper  punctum,  inflamed  the  conjunctiva :  and  it  was  not  tilJ 
after  several  days,  that  I  detected,  on  making  pressure  along  the 
course  of  the  upper  canal,  that  this  was  the  seat  of  the  disease. 

In  the  course  of  this  tedious  disease,  the  accumulated  mucus, 
also,  varies  much  both  in  quantity  and  in  quality.  For  instance, 
the  mucus  accumulates  more  rapidly  and  is  much  thicker  aftei 
taking  food  than  at  other  times.  The  secretion  of  it  is  very  plenti- 
ful, but  thinner  than  usual,  when  the  patient  continues  long  in  a 
moist  and  cold  atmosphere.  In  this  case,  the  over-filling  of  the  sac 
sometimes  takes  place  so  rapidly,  that  the  compression  of  the  orbi- 
cularis palpebrarum  in  the  action  of  winking  is  sufficient  to  evacu- 
ate the  sac  through  the  canals  to  such  a  degree  that  the  whole 
surface  of  the  eyeball  is  suddenly  overflowed,  and  the  puriform  fluic 
runs  down  upon  the  cheek.  After  the  patient  remains  for  a  short 
time  in  a  warm  and  dry  atmosphere,  the  morbid  secretion  becomes 
sparing  and  ropy.  We  find  that  this  chronic  blenorrhoea  almost 
completely  disappears  in  many  individuals  during  warm  weather, 
upon  which  the  yet  unexperienced  patient  and  the  unexperienced 
surgeon  are  apt  to  express  a  great  but  a  premature  joy,  for  on  the 
very  first  change  to  cold  and  wet  weather,  the  disease  most  fre- 
quently returns  as  before. 

During  chronic  blenorrhoea,  the  lachrymal  sac  is  extremel}'  liable 
to  repeated  attacks  of  inflammation  ;  in  which  the  sac  becomes 
distended,  the  integuments  over  it  inflamed,  swollen,  and  aflected 
wuth  pain,  and  the  nasal  duct  and  lachrymal  canals  completely 
obstructed.  Unless  the  inflammation  is  resolved,,  the  swelling 
points  like  an  abscess,  bursts,  and  discharges  slowly  the  puriform 
mucus  contained  in  the  sac.  If  still  neglected,  the  opening  is  very 
apt  to  degenerate  into  a  fistula,  and  sometimes  several  fistulous 
openings  form. 

This  disease  may  be  regarded  as  the  same  with  that  which  we 
have  considered  in  the  last  section,  only  modified  by  some  constitu- 
tional disorder,  in  most  cases,  by  scrofula.     There  are  other  peortions 


I  179  ,    , 

of  the  mucous  system,  the  inflammation  of  which  is  strikingly  modi- 
fied by  this  latter  cause.  Mr.  Hunter  "  suspected  that  there  was 
something  scrofulous  in  some  gleets ; "  *  and  with  a  gleet,  or 
chronic,  periodic,  puro-mucous  inflammation  of  the  urethra,  this 
disease  of  the  lachrymal  passages  presents  a  very  striking  analogy. 
Indeed  it  may  be  asserted  in  general,  that  the  effect  of  scrofula 
,upon  any  inflammatory  disease  is  to  prolong  its  second  stage,  and 
to  render  it  chronic.  In  other  cases,  this  chronic  blenorrhoea  of 
the  excreting  parts  of  the  lachrymal  organs  appears  to  depend 
upon  the  weakly  constitution  of  the  patient,  although  he  be  free 
from  scrofula ;  and  in  others,  it  is  evidently  kept  up,  and  in  some 
it  appears  to  be  produced,  by  the  disordered  state  of  the  digestive 
I  organs. 

Even  regarded  locally,  the  present  disease  is  seldom  a  primary 
I  affection,  but  is  frequently  excited  by  catarrhal  inflammation  of  the 
Schneiderian  membrane,  or  of  the  conjunctiva,  long  continued  dis- 
order of  the  Meibomian  glans,  or  a  stricture  of  the  nasal  duct.  In 
some  cases,  a  collection  of  puro-mucous  fluid  within  the  lachrymal 
sac  appears  to  arise  entirely  from  the  absorption  of  such  fluid  from 
the  eyelids,  where  it  is  secreted  in  consequence  of  blenorrhosal 
inflammation  of  the  conjunctiva,  or  of  inflammation  of  the  Meibo- 
mian foUicles  ;  and  this  absorbed  fluid,  exciting  inflammation  of  the 
I  lining  membrane  of  the  excreting  lachrymal  passages,  speedily 
I  becomes  the  source  of  additional  purifoim  mucus.  Inflammation 
^ of  the  Schneiderian  membrane  acts  by  the  sympathy  of  continuity 
in  bringing  on  this  disease.  As  for  stricture  of  the  nasal  duct,  it 
operates  both  as  cause  and  effect;  an  effect,  in  the  first  instance, 
and  then  a  powerful  cause  of  the  continuance  of  the  disease.  Very 
I  often  this  disease  is  complicated,  at  least  so  far  as  its  origin  is  con- 
.cerned,  with  other  constitutional  diseases  besides  those  already 
I  mentioned.  Small-pox,  measles,  and  scarlet  fever,  frequently  call 
into  action  an  occult  scrofulous  disposition,  and  at  the  same  time 
give  rise  to  the  particular  local  disease  which  forms  the  subject  of 
.this  section. 

Prognosis.  As  for  the  prognosis,  it  must  of  course  vary  ac- 
cording to  the  constitutional  cause  to  which  the  prolongation  of  this 
local  affection  is  to  be  attributed.  For  instance,  when  scrofula  is 
present,  much  depends  upon  whether  the  scrofulous  diathesis  be 
completely  developed  in  the  patient,  merely  commencing  to  declare 
itself,  or,  as  happens  at  certain  periods  of  life,  already  beginning  to 
retreat.  Very  frequently,  we  shall  find  it  impossible  to  effect  a 
cure,  while  the  scrofula  continues  in  activity  ;  and  a  similar  obser- 
vation may  be  made  in  regard  to  those  cases,  in  which  the  disease 
is  kept  up  by  the  weakly  constitution  of  the  patient,  or  by  the  dis- 
ordered state  of  his  digestive  organs.  Even  when  we  succeed  in 
removing  the  blenorrhoea,  we  cannot  pronounce  the  disease  to  be 
radically  cured,  nor  ought  the  patient  to  deviate  from  such  a  gene- 

*  Treatise  on  the  Venereal  Disease,  p.  159.     London,  1810. 


180 

ral  plan  of  treatment  as  the  bad  state  of  his  constitution  may  de- 
mand. 

The  oftener  a  blenorrhoea,  ah'eady  become  in  some  measure  ha- 
bitual, has  been  attended  with  new  attacks  of  inflammation,  the  less 
is  our  hope  of  ever  completely  curing  it.  If,  in  consequence  of 
these  renewals  of  inflammation,  a  fistula  of  the  sac  should  form, 
there  sometimes  follows  a  complete  closure  of  the  nasal  duct,  while 
the  mucous  membrane  of  the  sac  itself  becomes  so  thickened  and 
fungous  on  its  internal  surface,  that  the  parietes  approach  each 
other  more  and  more  nearly,  till,  at  last,  the  attacks  continuing  to 
be  repeated,  the  cavity  appears  to  be  obliterated. 

Should  the  tumefaction  and  induration  of  the  mucous  membrane 
and  of  the  surrounding  parts  become  so  great,  that  after  complete 
evacuation  of  the  sac,  the  sweUing  is  but  little  diminished  and 
scarcely  yields  to  the  pressure  of  the  finger,  the  cure  is  extremely 
tedious  and  rarely  comes  to  be  complete.  Both  the  nasal  duct  and 
the  sac  most  frequently  remain  in  this  case  impermeable,  and  even 
though  the  blenorrhcea  ceases,  a  stillicidium  lachrymarum  con- 
tinues. 

If  the  evacuation  of  the  sac  during  this  disease  be  left  entirely  to 
the  action  of  the  orbicularis  palpebrarum,  instead  of  being  carefully 
and  frequently  effected  by  pressure,  this  spontaneous  evacuation 
will  take  place  more  and  more  seldom,  the  sac  wiU  become  more 
and  more  over  distended,  the  swelling  even  after  the  most  complete 
evacuation  will  merely  subside  and  not  disappear,  and  a  manifest 
laxity  will  become  obvious  in  the  anterior  part  of  the  sac  and  in 
the  parts  by  which  it  is  covered.  This  is  a  particular  state,  of  v'hich 
I  shall  treat  in  a  subsequent  section,  under  the  name  of  relaxation 
of  the  sac. 

In  a  case  of  long  continued  blenorrhcEa  with  stillicidium,  1  ob- 
served the  pupil  of  the  eye  of  the  affected  side  become  expanded 
and  fixed,  and  vision  dim,  while  on  the  other  side  no  amaurotic 
tendency  was  manifest.  By  adopting  proper  measures  for  the  re- 
lief of  the  blenorrhoea,  the  amaurosis  was  removed. 

Local  Treat7nent.  The  local  treatment  of  chronic  blenorrhcea 
of  the  excreting  lachrymal  organs,  necessarily  varies  according  to 
the  particular  symptoms  which  are  present,  their  severity,  and  their 
duration.  The  objects  of  the  treatment  are  to  remove  the  inflam- 
mation and  puriform  discharge,  to  reMeve  the  swollen  state  of  the 
lining  membrane  of  the  passages,  and  to  restore  the  tears  to  their 
natural  course. 

1.  Injections.  I  have  occasionally  succeeded  in  completely 
curing  slight  incipient  cases  by  injections  with  Anel's  syringe,  but 
much  more  frequently  I  have  failed.  The  sac  is  first  to  be  emptied, 
and  if  possible,  emptied  into  the  nostril.  The  lachrymal  canals 
are  then  to  be  injected  with  tepid  water.  In  syiinging  the  upper, 
the  point  of  the  syringe  is  first  of  all  entered  from  below  upwards, 
till  it  reach  the  angle  of  the  canal ;  the  instrument  is  then  to  be 


181 

'turned  in  a  circle  till  its  point  comes  to  be  directed  downwards  and 
inwards,  while  at  the  same  time  we  draw  the  eyelid  somewhat  up- 
wards and  outwards.     In  syringing  the  inferior  canal,  we  introduce 
the  point  from  above  downwards,  and  then  lower  the  instrument 
jto  the  horizontal  position.     Continuing  to  carry  the  point  onwards 
;  in  the  directions  described,  it  enters  the  sac,  the  piston  is  now  press- 
ed down,  the  sac  is  filled  with  the  fluid,  and,  if  the  passage  is  free, 
jit  flows  from  the  nostril,  or  into  the  back  of  the  throat.     If  the  pas- 
I  sage  is  not  free,  the  sac  is  left  distended.     With  the  finger  we  en- 
ideavour  to  press  the  fluid  with  which  it  is  filled  down  into  the 
nostril,  placing  the  finger  for  this  purpose  between  the  puncta  and 
;  the  sac,  and  pressing  from  the  puncta  towards  the  nose,  not  from 
;  the  nose  towards  the  puncta.     We  then  take  up  with  the  syringe 
jthe  medicated  injection,  and  use  it  in  the  same  manner.     One  or 
;  two  grains  of  nitras  argenti,  or  from  two  to  four  grains  of  sulphas 
jzinci  to  the  ounce  of  distilled  water  will  be  sufficiently  strong. 
i  These  injections  are  to  be  repeated  once  every  day,  or  every  second 
I  day,  according  to  the  effects  which  they  produce.     If  they  irritate 
jmuch,  the  tepid  water  injections  only  are  to  be  used  ;  and  if  after  a 
I  fortnight  or  three  weeks,  no  improvement  has  taken  place,  neither 
'  in  the  discharge  nor  in  the  freedom  of  the  passage  into  the  nostril, 
i  they  may  be  laid  aside.     The  probability  is,  that  in  such  a  case, 
i  there  is  a  stricture  of  the  nasal  duct. 

i  Sir  William  Blizard  proposed  to  treat  cases  of  this  sort  by  filling 
the  lachrymal  sac  with  quicksilver ;  but  I  do  not  see  that  this  could 
be  of  any  service,  neither  in  chronic  blenorrhoea  nor  in  obstructed 
;  nasal  duct,  unless  in  a  very  early  stage  of  these  diseases.  The 
,  method  was  as  follows.  After  emptying  the  sac,  as  has  been  al- 
ready directed,  a  tube,  such  as  was  formerly  used  for  injecting  the 
lymphatics,  fitted  with  a  fine  steel  tubule  and  stop-cock,  was  taken, 
and  the  point  of  the  tubule  introduced  into  the  lower  punctum, 
mercury  poured  into  the  tube,  and  the  cock  opened.  The  mercury 
ran  through  the  tubule  into  the  sac,  fiUing  it,  descending  into  the 
nasal  duct,  and  if  the  duct  was  patent,  ran  into  the  nostril ;  but  if 
the  duct  was  obstructed,  the  mercury  regurgitated  by  the  upper 
punctum.  The  instrument  was  withdrawn,  and  the  patient  di- 
rected to  take  care  not  to  touch  the  eye,  but  to  allow  the  mercury 
to  descend  at  its  leisure  into  the  nose,  which,  from  its  gravity  and 
subtility,  it  scarcely  ever  fails  to  do  in  a  short  time,  unless  the  duct 
be  completely  obliterated.  Next  day,  or  two  days  after,  the  same 
process  is  to  be  repeated,  and  in  some  incipient  cases,  it  has  been 
found  of  use,  so  that  after  repeating  the  injection  half  a  dozen,  or  a 
dozen  times,  the  mercur}'^  is  seen  running  from  the  nose  in  a  stream, 
giving  evidence  at  least  of  there  being  no  considerable  obstruction 
of  the  nasal  duct. 

2.  Lotions.  These  are  of  two  sorts,  refrigerant  and  astringent ; 
the  one  to  be  applied  only  externally,  as  the  solution  of  acetas 
plumbi :  the  other  intended  to  be  taken  up  by  the  puncta  lachry- 


182 

malia,  and  conveyed  into  contact  with  the  lining  membrane  of  the 
sac  and  duct,  as  the  solution  of  nitras  argenti  or  sulphas  zinci.  The 
former  set  of  lotions  are  employed  by  means  of  a  fold  of  linen,  laid 
over  the  inflamed  integuments  ;  the  latter,  when  the  sac  has  been 
emptied,  are  poured  into  the  nasal  angle  of  the  eye,  the  patient 
lying  on  his  back,  and  are  allowed  slowly  to  reach  their  destina- 
tion. 

3.  iSalves.  These  are  employed  chiefly  when  the  conjunctiva 
and  Meibomian  follicles  are  affected.  The  red  precipitate  and  white 
precipitate  of  mercury  salves  are  generally  preferred.  Melted  on 
the  end  of  the  finger,  about  the  bulk  of  a  hemp  seed  of  either  is 
introduced  on  the  inside  of  the  lower  lid,  rubbed  along  the  edges  of 
the  lids,  and  into  the  neighbourhood  of  the  puncta  lachry malia. 
They  correct  the  unhealthy  state  of  the  parts  to  which  they  are 
applied  ;  and  may  perhaps  be  absorbed  by  the  puncta. 

3.  Leeches.  The  pain,  redness,  and  swelling  of  the  integu- 
ments during  a  renewal  of  the  inflammation,  will  evidently  de- 
mand the  employment  of  this  remedy  ;  but  even  when  the  ex- 
ternal signs  of  inflammation  are  not  such  as  to  attract  much  at- 
tention, when  the  sac  is  but  little  distended,  and  the  integuments 
scarcely  affected,  much  advantage  will  be  derived  from  the  repeat- 
ed application  of  leeches  over  the  seat  of  the  lachrymal  sac. 

4.  Poultices.  Should  we  fail  in  reducing  the  inflammation  by 
the  means  already  enumerated,  we  must  proceed  as  in  a  case  of 
acute  inflammation,  apply  an  emollient  poultice,  and  wait  till  the 
suppurating  sac  advances. 

5.  Incision  of  the  sac.  As  soon  as  the  fluctuation  of  the  ab- 
scess is  distinct,  w^e  lay  the  sac  open  as  has  been  directed  in  the 
last  section.  On  examining  the  nasal  duct,  we  almost  uniformly 
find  it  contracted  at  one  or  several  points  of  its  extent,  and  to  rem- 
edy this,  we  generally  introduce  the  headed  piece  of  silver  wire, 
called  a  style. 

6.  Style.  The  introduction  of  a  style  is  a  very  common,  and 
a  very  useful  method  of  treating  chronic  blenorrhoea,  not  merely 
after  a  renewal  of  inflammation,  terminating  in  abscess  of  the  sac, 
but  at  every  stage  of  the  complaint,  except  the  mere  incipient  one. 
It  is  an  instrument  which  may  be  worn  for  an  unlimited  time,  not 
only  without  annoyance  to  the  patient,  but  with  a  great  degree  of 
comfort.  The  eyelids  being  drawn  outwards,  so  as  to  put  the  ten- 
don of  the  orbicularis  palpebrarum  on  the  stretch,  an  incision  is 
made  with  the  lancet  into  the  sac.  Even  in  cases  w^here  the 
sweUing  is  small,  and  scarcely  any  external  inflammation  present, 
we  shall  be  surprised  at  the  large  quantity  of  matter  which  is  im- 
mediately discharged  on  opening  the  sac.  The  common  silver 
probe  is  now  introduced,  and  made  to  descend  through  the  nasal 
duct  till  it  strike  the  floor  of  the  nostril ;  the  probe  is  withdrawn, 
and  a  little  tepid  water  is  injected,  and  then  the  style  is  introduced, 
but  not  pushed  down  so  completely  that  its  head  comes  into  con- 


183 

tact  with  the  integuments,  till  a  bit  of  court  plaster  is  applied,  so  as 
to  bring  the  edges  of  the  incision  as  much  together  as  the  presence 
of  the  style  will  permit.  The  wound  closes  gradually  round  the 
style,  which  is  not  to  be  taken  entirely  out  for  the  first  four  or  five 
days,  but  merely  raised  a  little  daily,  so  as  to  allow  the  wound  to 
be  cleaned,  and  a  new  piece  of  court  plaster  inserted  below  the 
edge  of  the  head  of  the  style.  After  the  wound  has  healed  so  much 
that  the  opening  closely  embraces  the  style,  this  is  to  be  taken  out 
every  morning,  the  nasal  duct  injected  with  tepid  water,  or  with 
some  mild  astringent  solution,  and  .then  the  style  replaced.  The 
aperture  through  the  integuments  into  the  sac  soon  becomes  per- 
fectly fistulous,  having  no  disposition  to  close. 

During  the  time  that  the  style  is  worn,  the  blenorrhcea  disap- 
pears almost  completely.  The  tears  and  mucus,  absorbed  by  the 
lachrymal  canals,  would  appear  to  be  attracted  along  its  surface 
through  the  nasal  duct,  and  thus  the  function  of  the  parts  being 
restored,  the  inflammation  and  blenorrhceal  discharge  quickly 
subside. 

It  frequently  happens  that  a  patient,  after  wearing  a  style  for 
three  or  four  months,  has  it  removed,  thinking  the  disease  perfectly 
cured.  After  a  time,  however,  the  blenorrhcea  returns,  the  style 
is  reintroduced,  and  the  symptoms  subside.  After  three  or  four 
months  it  again  becomes  a  question,  whether  the  style  should  be 
removed.  The  patient  often  objects  to  this  being  done.  He  knows 
the  inconvenience  of  the  disease,  and  the  little  trouble  of  the  remedy, 
and  prefers  continuing  to  wear  the  style,  to  running  the  risk  of  the 
blenorrhcea  returning.  I  have  known  even  ladies  object  to  giving 
up  the  style,  having  once  experienced  a  relapse  from  the  removal 
of  it. 

The  head  of  the  style  may  be  covered  with  black  sealing  wax, 
and  then  it  looks  like  a  little  patch.  It  must  on  no  account  be  left 
without  regular  removal  and  replacement.  A  patient  in  the  lower 
ranks  of  life  called  upon  me  some  time  ago,  with  a  style,  which 
had  been  introduced  by  Dr.  Monteath,  and  which  had  not  been 
taken  out  for  more  than  six  months.  It  was  corroded  almost 
through,  about  a  quarter  of  an  inch  below  ihe  head. 

It  is  important  to  remark,  that  the  style  itself  is  occasionally  a 
cause  of  irritation.  It  often  is  so,  for  some  days  after  it  is  first  in- 
troduced. We  are  obliged  to  apply  an  emollient  poultice  over  the 
sac,  or  even  to  withdraw  the  style.  Months  after  it  has  been  in- 
troduced, and  proved  highly  serviceable,  we  find  that  the  patient 
complains  of  matter  being  still  discharged  by  the  side  of  the  style. 
In  such  cases,  we  should  consider  how  far  the  style  itself  is  a  cause 
of  this  discharge ;  and  if  the  Meibomian  follicles,  the  conjunctiva, 
and  the  lachrymal  passages,  appear  in  every  other  respect  to  be 
sound,  except  only  in  the  puro-mucous  discharge  by  the  side  of 
the  style,  let  it  be  removed,  and  a  trial  made  whether  every  thing 
'  will  not,  now  that  the  passage  is  patent,  go  on  as  it  ought  to  do. 


184 

When  we  remove  a  style  with  the  intention  of  no  longer  re- 
placing it,  we  must  make  raw  the  edge  of  the  opening  through 
the  integuments,  which  it  leaves  behind ;  for  if  this  is  not  done, 
it  is  apt  to  contract  to  an  almost  capillary  fistula,  very  difficult  to 
close. 

7.  Counter-irritation.  As  a  remedy  of  considerable  use  in 
chronic  blenorrhoea,  I  may  mention  blisters  and  issues  behind  the 
ears  and  on  the  nape  of  the  neck.  The  employment  of  sternuta- 
tories may  also  be  arranged  under  this  head.  By  the  discharge 
which  they  cause  from  the  nostril,  they  sometimes  prove  serviceable. 

8.  Electricity  has  frequently  been  serviceable  in  chronic  blen- 
orrhoea. The  method  which  has  been  found  successful  is  that  of 
drawing  theelectric  fluid  with  a  wooden  point,  or  taking  very  small 
sparks  from  the  part.  This  is  to  be  continued  for  three  or  four 
minutes  every  day.  When  an  obstruction  of  the  nasal  duct  is  sus- 
pected, electric  shocks  may  be  passed  down  the  duct,  by  placing 
one  director  upon  the  lachrymal  sac,  and  another  up  the  nostril.* 

Other  local  remedies  for  chronic  blenorrhoea  have  been  proposed, 
but  do  not  appear  to  deserve  notice. 

General  treatment.  However  well  chosen,  and  carefully  con- 
ducted our  local  treatment  of  this  tedious  and  troublesome  disease, 
we  shall  probably  find  it  to  have  comparatively  little  effect,  unless 
we  at  the  same  time  employ  every  means  we  possess  of  improving 
the  patient's  general  health. 

In  scrofulous  cases,  the  constitutional  treatment  consists,  in  a 
great  measure,  in  regulating  the  patient's  diet  and  manner  of  life. 
In  weakly  persons,  whether  scrofulous  or  not,  the  employment  of 
the  preparations  of  iron  and  cinchona  will  be  found  highly  bene- 
ficial. When  the  prolongation  of  the  disease  depends  on  derange- 
ment of  the  digestive  organs,  it  will  be  necessary  to  begin  by  re- 
storing these  to  a  healthy  state.  This  will  be  best  eflfected  by  small 
doses  of  blue  pill  at  bedtime,  followed  by  a  laxative  in  the  morning, 
as  has  been  recommended  by  Mr.  Abernethy,  in  his  Surgical  Ob- 
servations on  the  Constitutional  Origin  and  Treatment  of  Local 
Diseases.  In  almost  every  case,  advantage  will  be  reaped  from 
country  air  and  exercise. 


SECTION  IV. STILLICIDIUM  LACHRYMARUM. 

It  is  necessary  to  distinguish  this  disease  from  epiphora.  The 
cause  of  stiUicidium  lies  in  some  obstacle  to  the  absorption  and 
conveyance  of  the  tears  into  the  nostril.  Epiphora,  on  the  other 
hand,  consists  in  a  superabundant  quantity  of  tears,  and  is  a  dis- 
ease, therefore,  of  the  secreting,  not  of  the  excreting  parts  of  the 
lachrymal  organs. 

T  have  nothing  farther  to  add  to  what  has  been  said  in  the  pre- 

•  Cavallo  on  Electricity,  Vol.  ii.  pp.  149,  167,  186.    London,  1795. 


185 

ceding  sections,  regarding  stillicidium  as  a  symptom  merely  of  in- 
flammation of  the  sac  and  neighbouring  parts.  As  the  inflamma- 
tion subsides,  this  symptom  disappears.  Neither  do  I  mean  to 
treat  of  incurable  stillicidium,  arising  from  obliteration  of  any  of 
the  excreting  parts  of  the  lachrymal  organs.  The  stillicidium  now 
to  be  considered,  is  the  result  of  relaxation  of  the  puncta  and  ca- 
nals, attended,  it  is  probable,  with  atony  of  the  tensor  tarsi.  It  is 
most  frequently  a  sequela  of  inflammation,  continuing  after  all  the 
other  symptoms  have  disappeared  ;  and  is  to  be  regarded  as,  in 
general,  a  curable  disease. 

iS'i/?nptonis.  The  puncta  stand  widely  open,  and  are  turned 
forwards  from  the  conjunctiva  of  the  eyeball,  with  which  they  nat- 
urally are  in  contact.  They  appear  to  have  lost  their  contractile  and 
absorbing  power.  The  quantity  of  tears,  which  from  time  to  time 
roll  over  the  cheek,  is  not  considerable  ;  they  fall  in  single  drops,  at 
intervals,  and  only  from  the  nasal  angle  of  the  eye.  The  nostril 
belonging  to  the  atfected  side  is  dry,  as  little  or  none  of  the  fluids 
collected  in  the  lacus  lachrymarum  is  conveyed  into  the  sac,  there 
to  mix  with  the  mucus  secreted  by  its  lining  membrane,  and 
thence  to  be  discharged  into  the  nose.       * 

Erysipelatous  inflammation  of  the  eyelids,  or  of  the  integuments 
covering  the  lachrymal  sac,  and  puro-mucous  ophthalmia,  are  apt 
to  give  rise  to  the  present  kind  of  stillicidium,  and  to  the  patulous 
state  of  the  puncta,  upon  which  it  depends  ;  but  perhaps  the  most 
common  cause  is  an  injudicious  and  too  frequent  use  of  Anel's 
probes  and  syringe  in  the  treatment  of  chronic  blenorrhoea. 
Schmidt  mentions  two  cases  which  fell  under  his  observation,  in 
which  the  papillae  lachrymales  were  absolutely  split,  in  consequence 
of  the  repeated  introduction  of  these  instruments,  so  that  the  pa- 
tients were  left  with  incurable  stillicidium. 

Prognosis.  This,  in  ordinary  cases,  is  favourable  ;  for  the  dis- 
ease will  either  disappear  under  the  influence  of  warm  and  dry 
weather,  or  may  be  removed  by  the  careful  employment  of  astrin- 
gents. 

Treatment.  A  solution  of  borax  in  peppermint  water,  with  a 
small  quantity  of  camphorated  spirits,  or  of  tincture  of  opium ;  a 
solution  of  the  sulphate  of  iron  ;  or  a  pretty  strong  solution  of  the 
lapis  divinus,  with  the  same  addition  of  spirit  or  of  tincture,  may  be 
used.  These,  with  a  hair  pencil,  are  to  be  applied  to  the  relaxed 
puncta,  and  afterwards  dropped  into  the  nasal  angle  of  the  eye,  sev- 
eral times  a  day,  the  patient  lying  on  his  back  for  some  minutes  after 
the  application. 


SECTION  V. FISTULA  OF  THE  LACHRYMAL    SAC. 

It  must  be  apparent  from  what  has  been  said  in  the  foregoing 
sections,  that  this  disease  is  usually  the  consequence  of  mistreat- 
24 


186  . 

ment  or  neglect  of  the  acute  inflammation  of  the  excreting  lachry- 
mal organs,  or  of  reiterated  attacks  of  inflammation  in  the  same 
parts  during  the  course  of  chronic  blenorrhoea.  If  the  inflamed 
sac  be  not  opened  at  the  proper  time^  but  the  collection  of  puri- 
form  mucus  be  left  to  itself,  it  will  form  a  passage  through  the 
fibrous  layer  by  which  the  sac  is  covered,  the  orbicularis  palpebra- 
rum, and  the  integuments.  The  opening  thus  formed  may  close 
soon  after,  and  every  thing  go  on  well.  But  in  many  cases,  the 
opening-  merely  contracts,  manifests  no  disposition  to  heal,  and 
degenerates  into  a  fistula  of  the  sac. 

Symptoms.  While  employing  this  term  fistula,  let  us  not  for- 
get any  part  of  its  import.  It  implies  a  narrow  canal,  with  a  small 
opening,  the  circumference  of  which  is  hard  and  callous.  Through 
such  an  opening  into  the  lachrymal  sac.  then,  a  great  portion  of 
the  mucus  and  tears  taken  up  by  the  puncta  are  discharged,  very 
little,  or  none,  going  down  through  the  nasal  duct.  It  rarely  hap- 
pens that  the  opening  through  the  anterior  part  of  the  sac  is  directly 
opposite  to  that  which  has  been  wrought  through  the  fibrous  layer 
of  the  lower  eyelid,  the  orbicularis  palpebrarum,  and  the  integu- 
ments. It  even  someti?iies  happens,  that  though  there  be  but  one 
opening  into  the  sac.  the  matter  has  formed  beneath  the  skin  seve- 
ral sinuses,  which  open  by  small  orifices  at  different  places,  more  or 
less  remote  from  one  another.  This  complicated  kind  of  fistula 
occurs  inost  frequentl\^  in  patients  of  bad  constitution,  and  is  the  re- 
sult of  often  renewed  attacks  of  inflammation,  during  the  course  of 
chronic  blenorrhcEa.  In  such  palients,  it  occasionally  happens  that 
the  matter  penetrates  not  merely  through  the  anterior  part  of  the 
sac,  but  through  its  posterior  part  also,  and  through  the  os  unguis 
into  the  nose,  thus  causing  what  may  be  distinguished  by  the  name 
of  carious  fistula.  This  particular  variety  seldom  if  ever  occurs  un- 
less the  individual  is  affected  with  scrofula,  syphilis,  or  some  other 
constitutional  disease.  Even  when  inflammation  of  the  excreting 
parts  of  the  lachrymal  organs  is  in  the  greatest  degree  neglected^ 
caries  of  the  os  unguis  is  extremel)"  rare,  if  the  patient's  constitu- 
tion be  perfectl}^  healthy.  Lachrymal  fistula  is  occasionally  com- 
plicated with  a  fungous  state  of  the  sac,  and  generally  with  stric- 
ture of  the  nasal  duct. 

Prognosis.  The  least  disagi'eeable  circumstance  which  takes 
place  when  inflammation  of  the  sac  has  ended  in  fistula,  is  an  ex- 
ternal cicatrice  more  or  less  visible.  In  general,  the  cicatrice  is 
pretty  deep,  and  accordmg  to  its  depth  and  extent  it  invariably  pro- 
duces a  degree  of  ectropium.  In  every  case  of  fistula,  there  is  a 
danger  of  long-continued  atony  of  the  puticta  and  canals,  with  con- 
sequent stillicidium,  of  disorganization  of  the  canals  from  tedious 
suppuration  or  from  supervening  ulceration,  of  destruction  of  the  sac 
and  nasal  duct  from  the  same  causes,  and,  in  certain  states  of  the 
constitution,  of  caries  of  the  os  unguis.  If  the  fistula  be  allowed  to 
continue  for  a  great  length  of  time,  contraction  or  even  obliteration 


187 

of  the  nasal  duct,  from  disuse,  is  an  unavoidable  consequence.  The 
prognosis  is  favourable,  when  on  pressing  the  sac  a  quantity  of  tears 
issues  along  with  the  morbid  mucous  secretion,  although  not  mix- 
led  with  it ;  for  this  proves  that  the  absorption  of  the  tears  by  the 
puncta,  and  their  conveyance  into  the  sac,  by  the  canals,  are  re- 
stored. The  restoration  of  the  nasal  duct  only  now  remains 
doubtful. 

Treatment.  When  a  case  of  fistula  of  the  sac  presents  itself, 
we  have  first  of  all  to  examine  the  fistulous  opening  with  the  probe, 
and  to  ascertain  whether  the  fistulous  opening  of  the  integuments 
corresponds  or  not  with  that  of  the  sac.  If  they  correspond,  the 
point  of  a  lancet  is  to  be  introduced  into  the  fistula,  and  the  open- 
ing both  of  the  integuments  and  of  the  sac  enlarged  upwards  and 
downwards.  By  the  considerable  opening  thus  made,  a  quantity 
of  soft  lint,  moistened  with  the  vinous  tincture  of  opium,  is  to  be 
passed  into  the  sac,  but  not  to  such  a  depth  as  to  fill  or  stop  it  up. 
Over  the  lint  is  appKed  a  piece  of  adhesive  plaster,  and  over  the 
plaster  an  emollient  poultice  or  a  warm  cicuta  poultice  with  camphor. 
This  treatment  is  to  be  continued  till  no  trace  of  the  fistulous  hard- 
ness remains.  During  this  treatment  the  absorption  and  convey- 
ance of  the  tears  into  the  sac  are  frequently  re-established,  and  a 
similar  restoration  occasionally  extends  to  their  conveyance  into  the 
nostril.  To  ensure,  however,  an  immediate  transmission  of  the 
tears,  we  not  unfrequently  introduce  a  style  into  the  nasal  duct,  as 
soon  as  we  have  laid  open  the  fistula. 

When  the  fistula  is  complicated,  we  carefully  examine  with  the 
probe  the  fistulous  opening  or  openings,  and  ascertain  the  direction 
of  the  sinus  or  sinuses.  If  the  sinuses  are  superficial,  which  may 
sometimes  be  judged  to  be  the  case  from  the  discoloured  streaks 
which  are  seen  extendiiig  from  their  external  orifices  towards  the 
sac,  they  are  to  be  laid  open  with  a  small  bistoury,  quite  up  to  the 
sac.  The  opening  into  the  sac  is  then  to  be  enlarged  upwards  and 
downwards,  as  in  the  former  case.  The  same  treatment  also  as  in 
simple  fistula  is  to  be  followed. 

i  ,  Should  one  of  the  sinuses  be  so  deeply  seated,  that  in  order  to  lay 
it  open  it  would  be  necessary  to  divide  a  considerable  quantity  of 
muscular  substance,  vessels,  and  nerves,  we  content  ourselves  with 
enlarging  the  fistulous  opening  ;  after  which  we  pass  a  common 
silver  probe  along  the  sinus  to  its  commencement  in  the  sac,  and 
then  divide  the  integuments  immediately  over  the  end  of  the  probe, 
so  as  to  form  a  counter-opening  to  the  sinus.  Through  the  sinus, 
diluted  vinous  tincture  of  opium  is  daily  to  be  injected,  the  poultice 
applied  as  before  to  promote  the  removal  of  the  hardness  which  pre- 
vails throughout  the  sinus,  and  this  being  gained,  the  cure  is  to  be 
completed  by  compression.  So  long,  however,  as  any  hardness 
remains,  compression  is  of  no  use  ;  even  if  the  opening  heal  up,  the 
sinus  continues,  and  the  opening  after  a  while  returns.  As  for  the 
I'isac,  it  is  to  be  treated  as  in  the  former  case. 


188 

It  occasionally  happens  that  one  of  the  sinuses  is  so  deeply  situa- 
ted, that  a  portion  of  the  superior  maxillary  bone  over  which  it  runs 
is  laid  bare  or  becomes  carious.  When  this  is  the  case,  the  fistulous 
opening  is  surrounded  by  fungous  granulations,  an  ichorous  matter 
is  discharged,  the  integuments  around  are  of  a  deep  red  colour,  and 
the  denuded  or  carious  bone  is  felt  with  the  probe.  A  solution  of 
nitras  argenti  is  to  be  injected  into  the  sinus,  and  the  lint  with  which 
the  parts  are  dressed  is  to  be  moistened  with  tincture  of  myrrh. 

Such  is  the  treatment  of  the  different  varieties  of  fistula  of  the 
lachrymal  sac,  with  the  exception  of  that  variety  in  which  the  os 
unguis  is  carious,  a  subject  which  I  shall  consider  separately.  I 
have  only  farther  to  remark  under  the  present  head,  that  no  fistula 
is  to  be  allowed  to  close,  till  the  surgeon  shall  have  made  a  careful 
examination  of  the  state  of  the  lachrymal  canals  and  of  the  nasal 
duct,  and  satisfied  himself  of  the  permeability  and  eflfectiveness  of 
these  parts. 


SECTION  VI. CARIES  OF  THE  OS  UNGUIS. 

This  disease  is  much  less  frequent  than  it  was  once  supposed. 
"  For  my  own  part,"  says  Mr.  Sharp,  "  since  I  have  doubted  its 
frequency,  it  has  not  been  my  fortune  to  meet  with  a  single  instance 
of  it."  *  Janin  observes,  "  It  is  so  rare  to  find  this  bone  carious, 
that,  without  external  causes,  I  doubt  if  it  can  become  so.  Among 
the  gi'eat  number  of  diseases  of  the  lachrymal  sac  which  I  have 
treated,  I  have  found  only  a  single  case  of  caries,  and  this  was 
occasioned  by  a  gunshot  wound."  t  M.  Demours  puts  the  following 
questions  concerning  the  diseases  of  the  os  unguis.  "  Is  the  bone 
denuded  once  in  a  hundred  times  ?  In  those  cases  in  which  it  is 
denuded,  is  it  carious  once  in  twenty  times  ?  "  J 

It  cannot  be  doubted  that  carious  fistula  occasionally  arises  in 
the  manner  described  in  the  last  section.  Neither  is  there  any  doubt 
that  the  os  unguis  sometimes  becomes  affected  with  inflammation 
from  scrofula,  and  oftener  from  syphilis,  and  that  the  inflammation 
in  these  cases  may  terminate  in  caries.  The  idea  of  the  frequency 
of  caries  of  this  bone,  which,  notwithstanding  the  testimony  of 
Sharp  and  Janin,  has  continued  to  prevail,  appears  to  be  founded 
chiefly  upon  the  mismanaging  treatment  of  surgeons  themselves, 
and  above  all  is  to  be  attributed  to  their  rude  examination  of  the 
parts  with  probes  and  other  instruments.  A  patient  presents  him- 
self with  fistula  of  the  lachrymal  sac  ;  the  idea  of  caries  starts  up 
in  the  surgeon's  mind,  and  he  forthwith  takes  a  probe  in  order  to 
examine  whether  there  is  caries  or  not ;  he  penetrates  the  posterior 
part  of  the  lachrymal  sac,  touches  the  bone  with  the  point  of  the 

*  Treatise  of  the  Operations  of  Surgery,  p.  178.    London,  1758. 

t  Memoires  sur  I'CEil,  p.  119.    Lyon,  1772. 

J  Traite  des  Maladies  des  Yeux,  Tome  i.  p.  159.     Paris,  1818. 


189 

mstrument,  which  he  moves  about  to  this  side  and  to  that,  in  order 
to  make  himself  sure  of  what  he  is  seeking  for;  and  at  last  distinctly 
feehng  the  bone,  which  he  has  denuded,  he  pronounces  the  os  unguis 
to  be  carious, 

Syni'pto'ms.  In  cases  of  caries  of  the  os  unguis  from  scrofula  or 
syphilis,  the  swelling  is  more  deeply  seated,  and  the  symptoms  of 
disease  in  the  excretory  apparatus  of  the  tears  are  more  slowly  de- 
veloped than  in  primary  affections  of  these  parts.  For  some  time 
after  the  obscure  tumefaction  has  continued,  with  very  considerable 
pain,  in  the  neighbourhood  of  the  os  unguis,  the  excreting  lachrymal 
organs  continue  to  execute  their  functions  ;  whereas  the  tears  are 
no  longer  absorbed  nor  conveyed  into  the  nostril,  when  the  mucous 
membrane  is  the  part  first  affected.  At  length,  the  lachrymal  sac 
and  nasal  duct  becoming  inflam-ed,  the  symptoms  bear  a  nearer 
resemblance  to  those  described  in  the  preceding  sections.  The 
posterior  part  of  the  sac  becomes  ulcerated,  and  unless  some  suc- 
cessful plan  of  treatment  be  adopted  agaimst  the  constitutional  dis- 
ease, the  caries  of  the  bones  and  the  ulceration  of  the  soft  parts 
continue,  the  integuments  give  way  and  discharge  a  foetid  ichor, 
,  and  the  lachrymal  organs  may  be  entirely  destroyed. 
j  '^  General  treatment:  In  such  cases,  if  the  local  affection  depends" 
;  upon  syphilis,  the  proper  remedies  against  that  disease  are  to  be 
exhibited.  A  tonic  plan  of  treatment  must  be  followed  if  the  caries 
appears  to  be  of  scrofulous  origin.  A  course  of  Plummer's  pill  will 
generally  be  found  advantageous.  No  operation  practised  upon 
the  diseased  bone  can  be  of  any  use,  neither  while  the  scrofulous 
or  syphilitic  action  is  going  on,  nor  afterwards.  On  the  contrary, 
such  operation  would  in  all  likelihood  exasperate  the  disease,  and 
render  that  certain,  which,  even  in  the  least  unfavourable  case  of 
this  kind  and  under  the  best  directed  treatment,  is  scarcely  avoid- 
able, namely,  the  obliteration  of  the  lachrymal  sac. 

Local  treatment.  The  introduction  of  a  style,  and  the  cautious 
injection  of  a  solution  of  nitras  argenti,  make  up  the  local  treat- 
ment. The  former  serves  to  attract  the  tears  along  their  natural 
course,  while  the  latter  corrects  the  blenorrhoeal  discharge,  represses 
the  tendency  to  fungus,  and  improves  the  condition  of  the  bone. 


,j      SECTION    VII. RELAXATION    OF    THE    LA-CHRYMAL    SAC. 

tSympioms.  This  disease  presents  a  tumour  of  the  shape  and 
size  of  a  horse-bean  ;  the  integuments  covering  jt  are  scarcely  or 
not  at  all  discoloured,  it  is  not  painful,  and  it  yields  extremely  easily 
to  the  pressure  of  the  finger.  These  symptoms  are  suflficiently 
characteristic  to  distinguish  relaxation  from  mucocele. 

Upon  pressure,  the  contents  of  the  sac  in  the  state  of  relaxation 

i  are  discharged  either  by  the  canals  and  puncta,  or  by  the  nasal 

duct,  according  to  the  direction  in  which  the  pressure  is  applied. 


190 

The  fluid  is  usually  transparent,  or  presents  merely  a  streak  of 
whitish  matter ;  but  occasionally,  from  the  presence  of  blenorrhoea, 
it  is  entirely  yellowish  and  opaque.  Upon  evacuation  of  the  sac, 
the  tumour  is  indeed  for  an  instant  almost  completely  removed, 
but  its  integuments  remain  folded  and  wrinkled,  and  it  very  soon 
becomes  filled,  again.  If  the  fluid  does  not  consist  of  mucus  duly 
mixed  with  tears,  but  presents  whitish  streaks,  or  if  it  consists  en- 
tirely of  a  catarrhal  matter,  we  feel  a  little  elasticity  in  the  sac  after 
the  evacuation,  and  there  remains  some  degree  of  swelling.  These 
appearances  are  to  be  attributed  to  the  tumefaction  of  the  lining 
membrane  of  the  sac,  and  are  totally  wanting  in  the  more  common 
cases  of  relaxation. 

The  sac  in  this  disease  has  lost  its  natural  contractility  of  textute, 
Even  that  part  of  the  orbicularis  palpebrarum  which  covers  the 
sac,  and  to  which  the  duty  of  emptying  it  belongs  when  it  becomes 
filled  with  fluid,  having  suffered  from  long-continued  extension,  is 
incapable  of  contracting  with  a  suflflcient  degree  of  force,  and  is  in 
fact  exactly  in  the  state  of  the  muscles  of  the  abdomen  after  the 
removal  of  the  water  of  an  ascites.  The  patient  is  consequently 
obliged  to  do  with  his  finger,  what  ought  to  be  done  spontaneously 
by  the  parts  themselves.  He  is  obliged  to  evacuate  the  sac  by 
pressure  frequently  in  the  course  of  the  day,  and  it  is  fortunate  if 
he  begins  and  continues  the  practice  of  evacuating  it  by  the  natural 
route  through  the  nasal  duct,  and  not  through  the  lachrymal  canals. 

The  cause  of  relaxation  is  the  constant  over-distension  of  the 
sac  by  puriform  mucus,  during  previous  inflammation,  and  especially 
during  neglected  chronic  blenorrhoea.  Sometimes,  as  has  been 
already  stated,  the  blenorrhcea  still  continues,  or  has  recurred. 
Most  frequently  the  blenorrhoea  has  disappeared,  and  left  relaxation 
behind  it,  along  with  an  excessive  secretion  of  healthy  mucus. 
In  this  case  we  are  called  upon  to  limit  this  secretion,  and  to  restore 
their  natural  cohesion  and  elasticity  to  the  anterior  side  of  the  sac, 
the  orbicularis  palpebrarum,  and  the  integuments,  in  order  that 
the  orbicularis  palpebrarum  may  be  able  to  recommence  this  im- 
portant part  of  its  function,  the  evacuation  of  the  contents  of  the 
sac  through  the  nasal  duct. 

Prognosis.  The  prognosis  in  this  disease  is  always  favourable. 
The  distension  and  extenuation  of  the  anterior  side  of  the  sac,  and 
of  the  muscle  and  integuments  by  which  it  is  covered,  are  never 
to  such  a  degree  that  we  should  despair,  b}'  patient  and  proper 
treatment;  of  restoring  their  natural  and  elastic  force.  We  ought 
indeed  to  forewarn  the  patient  that  the  cure  wfll  be  tedious,  and 
require  much  attention  upon  his  part. 

Treatment.  This  consists  in  the  use  of  two  distinct  means, 
each  of  which,  as  may  be  seen  by  the  testiraou}^  of  Pellier  and 
others,  is,  when  used  alone,  apt  to  fail.* 

*  Pott,  Observations  on  the  Fistula  Lachrymalis.  Works,  Vol,  i.  p.  252.  Lon- 
don, 1808.  PeUier  de  Cluensy,  Cours  d'Operations  sur  la  Chirurgie  des  Yeux. 
Tome  ii.  p.  207.    Paris,  1790. 


191 

The  first  is  the  compression  of  the  sac ;  and  here  let  it  be  ob- 
served, that  the  present  is  the  only  case  in  which  compression  of 
the  sac  is  useful.  In  any  other  disease  of  that  part,  this  practice 
would  produce  the  most  destructive  effects.  The  compression 
must  be  carefully  applied,  constantly  continued,  and  gradually  in- 
creased. Machines  have  been  invented  for  this  purpose,  but  they 
never  fulfil  with  precision  all  these  conditions.  We  cannot  by 
such  an  instrument  as  Sharp's  or  Petit's  compressorium,  the  first 
invention  of  which  we  owe  to  Hieronymus  Fabricius,  keep  up  a 
regular  and  an  increasing  pressure  ;  the  compressing  surface  upon 
the  least  occasion,  especially  during  the  night,  is  disarranged;  and 
the  patient  is  hindered  from  pursuing  his  business  by  the  presence 
of  such  an  apparatus.  Graduated  compresses,  then,  are  to  be  pre- 
ferred ;  over  these  a  firm  leather  pad  of  a  proper  form  is  to  be 
placed  ;  and  the  whole  is  to  be  supported  by  a  narrow  roller  passing 
round  the  head.  In  this  manner  the  pressure  takes  place  exactly 
upon  the  part  which  ought  to  be  acted  upon  ;  it  can  be  daily  in 
creased ;  the  pad  cannot,  even  when  the  patient  is  very  restless, 
be  shoved  aside ;  nor  need  such  an  apparatus  prevent  him  from 
following  his  ordinary  employment,  even  out  of  doors. 

The  second  part  of  the  treatment  consists  in  the  application  of 
some  astringent  fluid,  both  to  the  external  surface  of  the  tumour, 
and  to  the  internal  surface  of  the  relaxed  sac.  A  great  variety  of 
astringents  might  be  mentioned  as  proper  for  this  purpose  ;  such  as 
the  sulphate  of  iron  or  of  copper  in  solution,  an  infusion  of  oak  bark, 
&c.  The  graduated  compresses  are  to  be  moistened  twice  or  thrice 
daily  with  the  astringent  fluid  which  shall  have  been  selected.  A 
small  quantity  also  of  the  same,  or  of  some  similar  fluid,  is  to  be 
dropped  into  the  lacus  lachrymarum,  and  left  to  be  absorbed  by  the 
puncta. 


SECTION  VIII. MUCOCELE  OF  THE  LACHRYMAL  SAC. 

Symptoms.  This  disease  presents  in  its  commencement  the 
oblong  shape  of  the  sac,  the  tumour  which  it  forms  slowly  increases, 
and  I  have  seen  it  reach  the  size  even  of  a  pigeon's  egg^  without 
bursting.  The  integuments  covering  the  tumour,  are  commonly 
of  a  livid  or  purple  colour,  and  this  colour  with  the  growth  of  the 
disease  becomes  darker.  A  mucocele  is  so  hard  that  it  scarcely 
yields  at  all  to  the  pressure  of  the  finger.  No  degree  of  pressure  is 
capable  of  evacuating,  either  through  the  puncta  or  into  the  nostril, 
the  mucus  which  in  this  disease  is  pent  up  within  the  lachrymal 
sac.  During  the  early  period  of  its  growth,  the  tumour  is  com- 
pletely devoid  of  pain.  It  is  not  until  the  over-filling  of  the  sac  has 
reached  its  highest  possible  degree,  and  the  mucocele  threatens  to 
burst,  that  the  patient  complains  of  a  painful  feeling  of  tension,  or 
rather  of  a  continual  sensation  of  pressure  in  the  nose,  in  the  region 


192 

of  the  eyebrow,  and  ia  the  eyeball.  If  we  touch  the  tumour  in- 
considerately, this  feeling  becomes  more  perceptible.  The  patierit 
at  this  period  can  no  more  than  half  open  his  eyelids  on  account  of 
the  size  of  the  tumour. 

Tn  examining  a  mucocele  of  the  lachrymal  sac,  we  distinguish 
only  a  very  indistinct,  and  in  many  cases,  not  the  least,  fluctuation. 
This  depends  upon  the  consistence  of  the  contained  mucus,  and 
the  presence  of  indistinct  fluctuation,  or  its  total  absence  merits  our 
attention  when  we  come  to  open  the  mucocele,  as  the  operation  is 
modified  accordingly.  The  contained  mucus  may  be  in  some 
measure  hquid,  or  it  may  have  acquired  a  gluey  consistence.  In 
the  former  case,  the  colour  of  the  integuments  is  purplish,  an  in- 
distinct fluctuation  is  felt,  the  tumour  is  still  a  little  elastic,  and  does 
not  exceed  the  size  of  a  horse-bean  ;  the  mucocele  is  not  yet  in- 
veterate ;  it  probably  has  continued  not  above  a  few  weeks.  In 
the  latter  case,  the  colour  of  the  integuments  is  blue  like  that  of  a 
varicose  vein,  the  mucocele  feels  like  a  pebble,  and  presents  not  the 
slightest  degree  of  fluctuation  ;  the  tumour  is  already  so  large  as  to 
rise  over  the  caruncula  lachrymalis  ].  the  disease  is  of  at  least  seve-| 
ral  months'  continuance.  i 

The  colour  of  the  integuments  in  mucocele  has  led  some  authors 
to  describe  this  disease  under  the  name  of  varix  of  the  lachrymal 
sac ;  while  the  hardness  and  size  of  the  tumour,  added  to  its  colour, 
have  sometimes  led  to  the  extirpation  of  the  lachrymal  sac  affected 
with  mucocele,  under  the  idea  that  it  was  a  cancerous  tumour. 

Causes.  Mucocele  is  the  consequence  of  an  obstructed  state  of  i 
the  lachrymal  canals  and  nasal  duct.  The  natural  secretion  of 
mucus  from  the  internal  surface  of  the  sac  goes  on,  but  as  it  can 
neither  be  diluted  by  the  tears,  discharged  into  the  nose,  nor  com- 
pletely re-absorbed  by  the  membrane  which  secretes  it.  it  accumu- 
lates, and  forms  the  tumour  in  question. 

Mucocele  very  rarely  occurs  after  the  inflammation  of  the  excre- 
ting lachrymal  organs  has  been  so  violent  as  to  cause  the  absolute 
obliteration  of  the  nasal  duct.     When  the  inflammation  is  so  vio- 
lent as  to  efiect  this,  it  almost  constantly  produces  at  the  same  time 
an  obliteration  of  the  sac.     The  sides  of  this  cavity  come  together, 
and  the  texture  of  its  parietes  is  so  altered  by  the  inflammation, 
that  the  sac  is  incapable  of  returning  to  its  natural  caliber.  Neither 
mucocele  nor  relaxation  can  ever  afterwards  take  place,  and  the 
case  is  incurable.     It  is  upon  obstruction  then,  and  not  obliteration  I 
of  the  nasal  duct,  that  the  origin  of  mucocele  usually  depends,  and  j 
this  obstruction  is  accompanied  by  a  similar  affection  of  the  lachry-  i 
mal  canals.     Yet  cases  of  mucocele  do  occasionally  occur,  in  which  I 
both  the  lachrymal  canals  and  the  nasal  duct  are  absolutely  obhte- 
rated. 

Prognosis.  When  a  patient  presents  himself  with  a  mucocele 
of  the  lachrymal  sac,  the  question  is  not  whether  we  can  remov^ 
the  tumour  merely.  We  know  that  we  can  always  lay  open  the 
sac,  clear  out  its  contents,  and  thus  remove  the  mere  mucocele. 


i 


193 

The  important  question  is,  whether  the  absorption  and  conveyance 
of  the  tears  into  the  sac,  and  their  evacuation  into  the  nose,  can  be 
restored  ;  but  to  enable  us  to  answer  this  question,  it  is  necessary 
to  open  the  sac,  and  to  clear  out  the  accumulated  mucus.  When 
the  mucocele  has  not  been  the  immediate  consequence  of  a  violent 
inflammation,  we  have  reason  indeed  to  hope  for  a  favourable  is- 
sue, even  before  the  sac  is  laid  open,  and  the  real  state  of  the  ca- 
nals and  duct  ascertained. 

.  Treatment.  The  opening  of  the  sac  is  to  be  performed  with  a 
lancet  fixed  in  a  handle.  The  instrument  is  to  be  introduced  into 
the  most  prominent  part,  and  pushed  on  till  its  point  has  reached 
the  centre  of  the  tumour.  The  wound  is  then  to  be  enlarged  up- 
wards and  downwards  in  the  direction  of  the  length  of  the  sac, 
both  that  its  contents  may  be  easily  evacuated,  and  that  we  may 
be  able  to  go  on  without  difficulty  in  the  remaining  stages  of  the 
treatment.  In  performing  this  operation,  as  well  as  in  enlarging  a 
fistula  of  the  lachrymal  sac,  it  is  better  to  avoid  if  possible  dividing 
the  tendon  of  the  orbicularis  palpebrarum.  Yet  the  inconvenience 
arising  from  cutting  that  tendon  across  is  much  less  than  might 
have  been  supposed ;  for  after  the  wound  has  healed,  the  eyelids 
retain  their  natural  position,  and  the  muscle  performs  its  functions 
as  before.  This  is  to  be  attributed  partly  to  the  ligamentous  layer 
which  lies  beneath  the  muscle  and  supports  the  eyelids,  and  partly, 
as  Mr.  Sharp  has  remarked,  to  the  firm  cicatrice  which  is  left  when 
the  cure  is  completed.* 

If  the  mucus  be  liquid,  a  little  of  it  issues  as  soon  as  the  incision 
has  been  completed.  The  remainder  is  to  be  cleared  out,  by 
means  of  a  small  syringe  introduced  by  the  wound,  and  through 
which  a  quantity  of  water  is  to  be  repeatedly  injected.  If  the 
mucus  has  entirely  lost  its  fluidity,  so  as  to  resemble  glue  in  colour 
and  consistence,  it  is  to  be  extracted  by  the  repeated  introduction 
of  a  small  pair  of  forceps.  After  the  mucocele  has  by  this  means 
been  pretty  well  emptied,  a  probe  is  to  be  introduced,  and  moved 
about  so  as  to  dislodge  any  of  the  inspissated  mucus  that  may 
remain.  The  sac  is  then  to  be  completely  washed  out  by  injecting 
tepid  water. 

A  small  quantity  of  soft  lint  is  now  to  be  placed  within  the  lips 
of  the  wound,  and  covered  with  a  piece  of  court-plaster.  Next  day, 
the  lachrymal  canals  and  nasal  duct  are  to  be  examined,  and  the 
causes  upon  which  the  mucocele  had  depended  being  ascertained, 
the  proper  treatment  is  to  be  commenced. 


SECTION    IX. — OBSTRUCTION   OF    THE    PUNCTA     LACHRYMALIA 
AND    LACHRYMAL    CANALS. 

The  puncta  lachrymaha  are  sometimes  congenitally  wanting. 
This  may  or  may  not  be  attended  by  defect  of  the  lachrymal 

'*  Treatise  of  the  Operations  of  Surgery,  p.  181.     London,  1758. 

25 


194 

canals.     If  no  vestige  of  the  puncta  can  be  discovered,  the  case 
is  hopeless. 

In  another  set  of  cases,  the  puncta  are  contracted,  but  are  stil 
patent,  and  may  easily  be  opened  with  the  point  of  a  middle-sizec 
pin.  after  which  Anel's  probe  will  pass  without  difficulty. 

The  lachrymal  canals  are  sometimes  stopped  up  by  calcareous 
depositions  from  the  tears.  "In  mOiC  than  one  instance,"  ?^ys 
Mr.  Travers,  '•  I  have  turned  out  a  considerable  quantity  of  calca- 
reous matter  wedged  in  these  ducts,  like  the  calculi  of  the  salivary 
ducts."* 

The  most  frequent  cause  of  obstruction  of  the  canals  is  tumefac- 
tion of  their  lining-  membrane,  continuing  after  all  the  other  symp- 
toms aitendant  on  acute  or  chronic  inflammation  of  the  secreting 
lachrymal  organs  have  disappeared. 

If  an  artificial  opening  has  been  made  into  the  sac  during  in- 
flammation, or  if  a  fistula  of  the  sac  has  formed,  neither  the  artifi- 
cial opening  nor  the  fistula  is  to  be  healed  up,  till  the  state  of  the 
lachrymal  canals  has  been  ascertained.  The  state  of  the  canals  is 
also  to  be  ascertained  on  the  day  following  the  opening  of  a  muco- 
cele. In  all  these  cases,  the  examination  of  the  canals  is  to  be  per- 
formed in  the  same  manner. 

In  this  examination  it  is  our  object  to  ascertain,  not  merely  whe- 
ther the  lachrymal  canals  be  obstructed,  but  also  the  cause  of  their 
obstruction.     This  may  depend  upon   the  presence  of  inspissatedj 
mucus,  tumefaction  of  their  lining  membrane,  stricture,  or  absolut 
obliteration  in  a  part  or  throughout  the  whole  of  their  extent. 

For  the  examination  of  the  canals,  we  make  use  of  Anel's  probe^ 
w^hich  is  to  be  held  like  a  writing  pen,  in  the  right  hand  if  we  are 
to  operate  on  the  left  side,  and  vice  versa.  The  little  finger,  ap 
plied  to  the  cheek,  is  to  serve  as  a  support.  By  means  of  the  fingers 
of  the  hand  which  does  not  hold  the  probe,  the  eyehd  is  to  be  drawn 
somewhat  towards  the  temple,  so  as  to  be  put  on  the  stretch  ;  and 
the  edge  of  the  eyelid  to  be  brought  a  little  forward,  so  as  to  bring 
the  punctum  into  view.  If  we  are  examining  the  superior  canal, 
we  first  of  all  introduce  the  point  of  the  probe  into  the  punctum 
from  below  upwards  till  it  reach  the- angle  of  the  canal.  We  now 
turn  the  instrument  in  a  circle  till  its  point  comes  to  be  directed  ob- 
hquely  downwards  and  inwards,  while  at  the  same  time  w^e  draw 
the  eyelid  somewhat  upwards  as  well  as  outwards.  If  we  are  ex- 
amining the  inferior  canal  we  introduce  the  point  of  the  probe  intc 
the  punctum  from  above  downwards,  and  then  lower  the  handle  of 
the  instrument  to  a  horizontal  direction.  If  upon  continuing  to 
press  the  probe  onwards  in  the  directions  described,  it  enters  the  sac, 
so  that  we  come  to  touch  the  nasal  side  of  that  cavity  with  the 
point  of  the  instrument,  we  are  assured  that  there  is  no  obliteration 
of  the  canals.  If  an  obhteration  exists,  a  state  of  the  canals  which 
we  may  partly  suspect  beforehand  from  the  contracted  appearance 

•  Synopsis  of  the  Diseases  of  the  Eye,  p.  238.    London,  1820. 


195 

)f  the  papillae  and  puncta,  we  find  an  inconquerable  obstacle  to  the 
oassage  of  the  probe,  and  ascertain  at  once  the  extent  and  situation 
of  the  obUteration. 

When  the  presence  of  mucus  is  the  sole  cause  of  the  obstruction, 
fhe  conveyance  of  the  tears  through  the  canals  is  immediately  re- 
stored by  carrying  the  probe  onwards  into  the  sac.  When  there  is 
lumefaction  of  the  mucous  membrane,  the  conveyance  of  the  tears 
s  not  restored  by  merely  sounding  the  canals,  for  as  soon  as  the 
probe  is  withdrawn,  the  contraction  of  their  caliber  returns.  Such 
,umefaction,  indeed,  depends  in  every  case  upon  inflammation,  and 
consequently  will  subside  only  as  this  disappears. 

In  any  doubtful  case,  we  can  easily  convince  ourselves  of  the  real 
'?tate  of  the  canals  after  sounding  them,  by  dropping  a  small  quanti- 
,y  of  an  aqueous  solution  of  saffron,  or  any  other  mild  highly- 
joloured  solution,  into  the  lacus  lachrymarum  while  the  patient  hes 
m  his  back.  If  the  canals  execute  their  office,  the  fluid  will  dis- 
appear from  the  lacus  lachrymarum  without  faUing  down  upon  the 
:heek,  and  will  show  itself  distinctly  by  its  colour  at  the  opening  of 
he  sac. 

When  one  or  both  of  the  canals  are  contracted  or  obliterated 
iirough  a  small  part  of  their  extent,  for  instance  for  the  length  of 
i  line,  we  ought  to  force  the  probe,  but  not  violently,  through  the 
^stricture  or  obUteration  into  the  sac.  The  edges  of  the  eyeUds 
ought  to  be  kept  moist  for  some  days  after  with  a  thin  and  mild 
')intment,  and  the  probe  passed  daily  along  the  canal  into  the  sac. 

When  the  canals  are  completely  obliterated,  I  know  no  means  of 
preventing  an  incurable  stillicidium.  It  is  easy  to  describe  methods 
■)f  making  new  puncta  and  canals,  but  it  is  another  matter  to  get 
iiese  new  puncta  and  canals  to  absorb  and  convey  the  tears.  In 
^;uch  a  case  some  have  recommended  to  lay  the  sac  completely  open, 
'ipply  lunar  caustic  to  its  lining  membrane  so  as  to  excite  a  degree 
of  inflammation,  and  then  by  moderate  compression,  endeavour  to 
;l;ecure  the  obliteration  of  its  cavity,  or  to  dress  it  for  sometime  with 
strong  red  precipitate  ointment,  and  gradually  to  allow  it  to  contract. 
'These  means  are  recommended  for  the  purpose  of  preventing  a 
fmucocele  of  the  sac. 


'  SECTION    X. -OBSTRUCTION    OP    THE    NASAL    DUCT. 

The  examination  of  the  nasal  duct,  equally  with  that  of  the 
I  achrymal  canals,  is  to  be  instituted  before  healing  up  any  artificial 
opening  or  fistula  of  the  sac  ;  it  is  also  to  be  instituted  on  the  day 
ifter  a  mucocele  has  been  laid  open. 

I  The  best  instrument  for  examining  the  nasal  duct  is  a  common 
jsilver  probe.  This  is  to  be  introduced  horizontally  till  it  touches 
.he  nasal  side  of  the  sac,  it  should  then  be  raised  into  a  vertical  po- 
sition, and  its  point  diiected  downwards  and  a  little  backwards. 
jiTurning  the  probe  upon  its  axis,  we   pass  it  from  the  sac  into  tlie 


196 

duct :  and  as  we  continue  to  press  it  gently  downward:,  the  instru- 
ment, if  the  duct  is  perviouS;  enters  into  the  nose.  If  its  point 
meets  \\ith  some  obstruction;  we  must  not  immediately  conclude 
that  there  is  an  obliteration  of  the  duct.  We  must  press  down  the 
probe  a  httle  more  strongly,  yet  without  violence  :  turning  it  round 
between  the  fingers,  and  giving  it  different  directions.  By  these 
means  the  obstacle  may  frequently  be  overcomej  and  the  probe  will 
suddenly  descend. 

If  the  obstacle  remains  as  before,  and  is  extremely  firm,  still  this 
is  not  sufficient  ground  for  us  to  conclude  that  there  is  a  real  oblit- 
eration :  because  there  are  many  other  causes,  particularly  diseased 
states  of  the  mucous  membrane,  from  which  the  dilficulty  we  en- 
counter may  proceed.  That  membrane  may  be  tumefied,  its  mu- 
cous cryptae  enlarged  and  indurated,  and  thereby  the  caliber  of  the 
duct  nrore  or  less  diminished,  yet  these  obstacles  may  be  capable  of 
pelding.  so  that  by  considerable  pressure  we  may  succeed  in  pass- 
ing the  probe  into  the  nose.  In  other  cases,  the  tumefaction  and 
induration  of  the  mucous  membrane  may  }ield  so  Uttle,  as  to  ren- 
der it  impossible  to  reach  the  nose  with  a  probe  of  the  ordina  ^ 
size,  so  that  it  requires  great  patience  to  pass  a  small  silver  pro;.: 
through  the  duct. 

If  we  cannot  reach  the  nose  with  the  small  probe,  if  its  point  hii 
constantly  against  the  same  unyielding  obstacle,  if  we  are  able  ic 
press  it  down  with  veiy  considerable  force  without  the  patient  com- 
plaining of  any  painful  feeling,  there  is  great  cause  to  suspect  an 
absolute  obliteration  of  the  duct.  The  probe  being  carried  down  tc 
the  obstacle,  we  lean  our  hand  over  the  brow  of  the  patient,  and 
holding  the  instrument  firmly  between  the  thumb  and  index-finger 
increase  the  pressure  till  it  has  sunk  to  the  farther  depth  of  half  a 
line  or  a  line.  We  suddenly  relax  the  pressure.  If  the  probe  risee 
from  the  obstacle  as  from  an  elastic  cartilage,  the  patient  during 
the  whole  of  this  experiment  feehng  no  pain,  we  may  safely  con- 
clude that  the  duct  is  obliterated.  From  the  depth  to  which  the 
probe  can  be  passed,  we  ascertain  the  distance  of  the  obliteratior 
from  the  termination  of  the  duct. 

Though  the  nasal  duct  is  only  seven-twelfths  of  an  inch  ir 
length,  there  are  three  points  in  its  course  at  which  stricture  is  par- 
ticularh'  apt  to  occur.  One  of  these  is  exactly  where  the  sac  end; 
and  the  duct  begins.  The  caliber  of  the  duct  is  there  narrowed  bj 
a  circular  fold,  the  thickening  of  which  frequently  causes  the  ob- 
struction. Janin  details  the  appearances  upon  dissection  of  a  stric 
ture  in  this  situation,  and  describes  the  mucous  membrane  of  th' 
duct  as  presenting  a  plaited  appearance  like  the  sleeve  of  a  shirt  a^ 
the  wrist.*  A  second  fold  of  tlie  same  kind  occurs  in  the  middlf 
of  the  duct,  in  many  subjects,  though  not  in  all :  "^  and  hence  th^ 

*  Memoires  sur  rrF.il  p.  115.  Lvon,  1T7'2. 

t  Soemmerriag,  Abbildungen  des  Menschlichen  Auges,  p.  32.  Frankfurt  an 
Main,  1501. 


197 

part  becomes,  from  a  similar  cause,  the  frequent  seat  of  stricture, 
'  The  third,  and  perhaps  the  most  usual  situation  of  stricture,  is  at 

the  termination  of  the  duct  in  the  nostril. 

If  we  succeed,  though  it  may  not  be  without  great  difficulty  and 
1  after  many  trials  repeated  during  several  days,  in  bringing  a  probe 

■  into  the  nose,  which  we  can  easily  recognise  by  the  hitting  of  the 
I  end  of  the  instrument  against  the  floor  of  the  nostril,  as  M^ell  as  from 

the  feehng  of  the  patient,  we  remain  convinced  that  it  is  yet  possi- 
ble to  restore  the  whole  excretory  apparatus  of  the  tears  to  the  ex- 
ercise of  its  function. 

In  order  to  treat  of  the  restoration  of  the  nasal  duct  with  precision, 

f  I  shall  consider  three  different  cases.     The  first  is  when  we  have 

already  passed  a  probe  through  the  duct.     The  second  is  when  we 

I  do  not  at  first  succeed  in  passing  a  probe,  but  in  which  it  is  yet 

possible  to  pass  it.     The  third  case  is  when  it  is  impossible  to  pass 

any  probe  through  the  natural  caliber  of  the  duct. 

First  Case.  If  we  have  succeeded  with  the  silver  probe,  we 
ought  immediately  to  introduce  a  nail-headed  silver  style  of  the 
same  size,  and  about  an  inch  and  a  quarter  long,  into  the  duct. 
We  now  proceed  progressively  to  restore  the  duct  to  its  natural  cal- 
iber. This  may  loe  done  by  a  series  of  silver  styles  gradually  in- 
creasing in  thickness,  or  by  a  similar  series  of  gum-elastic  bougies. 
Beer  employed  for  this  purpose  the  common  catguts  of  the  viohn. 

He  began  with  the  catgut  E.  Having  softened  its  point  between 
I  the  teeth,  made  seven  or  eight  inches  of  it  perfectly  straight,  and 
)  dipped  it  in  a  httle  oil,  he  introduced  it  first  horizontally  and  then 
t  vertically  into  the  sac,  and  hence  into  the  duct.     He  pushed  it 

■  down  slowly,  till  five  or  six  inches  of  it  had  descended,  in  order 
that  its  inferior  extremity  might  be  drawn  forth  from  the  nostril 
without  difficulty,  a  part  of  the  operation  which  was  left  to  the  pa- 
tient. The  superior  part  of  the  catgut  was  coiled  up,  inclosed  in  a 
piece  of  linen,  and  fastened  under  the  hair  of  the  forehead.     Into 

\  the  opening  of  the  sac  a  little  lint  was  laid,  and  over  that  a  piece  of 
'  court-plaster  was  apphed. 

The  patient  was  directed  to  try,  after  two  or  three  hours,  to  bring 
'  the  inferior  end  of  the  catgut  out  of  the  nose,  by  shutting  his  mouth 
i  and  the  opposite  nostril,  and  driving  the  air  through  the  nostril  into 
I  which  the  catgut  had  descended.  When  he  felt  it  advance,  with 
i  the  blunt  end  of  a  knitting  needle,  he  drew  it  out  of  the  nostril, 
!  turned  up  its  extremity  to  the  side  of  the  nose,  and  fixed  it  th^re 
t  by  a  slip  of  court-plaster. 

'      On  the  following  day  the  lint  was  removed  from  the  opening  of 

the  sac,  and  a  quantity  of  one  of  the  collyria  which  shall  be  after- 

1  wards  enumerated,  was  injected  by  the  side  of  the  catgut.     This 

■  injection  was  intended  as  well  to  wash  away  any  mucus  accumu- 
lated in  the  sac,  as  to  act  upon  the  mucous  membrane.  The 
superior  end  of  the  catgut  was  now  loosened  from  the  forehead,  a 
sufficient  fresh  portion  undone  from  the  coil,  and  being  besmeared 


198 

with  one  of  the  substances  which  I  shall  mention,  drawn  into  the 
duct  by  the  patient  taking  hold  of  the  extremity  which  hung  from 
the  nose.  The  portion  of  catgut  which  had  been  used  during  the 
preceding  day  was  now  cut  otf,  and  the  new  end  turned  up  to  the 
side  of  the  nose,  and  there  fastened  as  before.  The  same  injection 
was  now  repeated,  the  lint  and  plaster  appUed  to  the  opening  of  the 
sac,  and  the  coil  of  catgut  bound  up. 

In  this  manner  Beer  proceeded  day  after  day  till  the  catgut  E 
was  completely  used.  When  it  came  to  an  end,  the  patient  pulled 
it  out  of  the  nose. 

Before  proceeding  to  pass  a  new  catgut,  the  point  of  the  syringe 
was  introduced  through  the  sac  into  the  duct,  and  a  quantity  of 
tepid  water,  coloured  with  vinous  tincture  of  opium,  injected,  care 
being  taken  to  observe  whether  any  part  of  the  fluid  was  discharged 
by  the  nostril. 

The  catgut  A  was  now  passed  as  E  had  formerly  been,  and  its 
use  was  continued  exactly  in  the  same  manner.  When  it  was 
finished,  the  injection  of  a  coloured  fluid  was  repeated,  in  order  to 
ascertain  what  progress  had  been  made  in  restoring  the  natural 
diameter  of  the  duct. 

The  catgut  D  followed.  After  its  use,  the  injection  was  almost 
constantly  found  no  longer  to  drop  merely,  as  it  formerly  had  done, 
but  to  flow  freely  from  the  nostril.  Were  this  not  the  case  after 
the  employment  of  one  D,  this  catgut  was  repeated  till  the  injection 
was  discharged  from  the  nose  in  a  full  stream.  Then,  and  not  till 
then,  the  treatment  was  brought  to  a  close. 

If  the  mucous  membrane  of  the  duct,  when  the  use  of  the  catguts  ' 
was  commenced,  was  merel}"  somewhat  tumefied,  and  opposed  no 
great  obstacle  to  the  probe,  the  portion  of  catgut  daily  introduced 
was  moistened  with  the  vinous  tincture  of  opium,  and  a  quantity 
of  the  solutio  lapidis  divini  *  made  lukewarm,  was  injected  by  the 
sac.  The  lint  too,  with  which  the  wound  of  the  sac  was  dressed, 
was  dipped  in  the  vinous  tincture  of  opium. 

If  the  tumefaction  of  the  mucous  membrane  was  firm,  so  that 
the  silver  probe  could  not  be  brought  into  the  nose  without  much 
opposition,  the  catgut  was  besmeared  with  citrine  ointment,  at  first 
very  much  diluted,  but  gradually  increased  in  strength.  The  same 
ointment  was  apphed  to  the  wound.  For  an  injection  in  the  same 
case,  a  solution  of  corrosive  sublimate  was  employed,  together  with 
some  vinous  tincture  of  opium.  If  the  cryptee  of  the  mucous  mem- 
brane were  indurated  and  enlarged,  so  ihatthe  probe  was  felt  pass- 
ing successively  over  a  number  of  little  knots,  a  weak  ointment  of 
red  precipitate  was  employed  for  besme;iring  the  catgut,  and  the 
patient  was  directed  daily,  before  the  catgut  was  drawn,  to  rub  in  a 

*  R;     jEruginis,  Nitri  puri,  Aluminis,  utriusque  pulverisati  §  iii.     Liquefjantin  } 
vase  vitreo  in  bain eo  arenas.    Liquefactis  adde  Camphorae  tritte  5  is*'-    Misce.     Massa  !1 
refrigerata  servetur  sub  nomine  Lapidis  Divini.    J{;  Lapidis  Divini,  gr.  x — xx.    Aqua  It 
distillatce,  §  ss.     Solve,  et  cola.     Colato  adde  Vidi  Upii.  5i — 5ii-     Aqus  Rosarum, 
§  iv.     Misce. 


199 

small  quantity  of  camphorated  mercurial  ointment  around  the 
opening  of  the  sac. 

Similar  applications  may  be  used,  if  we  prefer  gum-elastic  bougies, 
or  silver  styles,  for  restoring  the  nasal  duct  to  its  natural  caliber. 
Whichever  of  these  instruments  we  select,  its  employment  must  be 
continued  for  several  months,  and  the  wished-for  restoration  effected 
extremely  gradually,  knov/ing  that  if  we  remove  the  stricture  or 
obstruction  suddenly,  it  will  almost  to  a  certainty  return. 

When  we  consider  ourselves  w^arranted  to  discontinue  the  dilating 
instrument  which  we  have  employed,  we  place  the  patient  on  his 
back,  and  repeat  the  experiment  of  dropping  a  deeply-coloured  fluid 
into  the  lacus  lachrymarum  ;  for  the  little  valvular  fold  which  in 
many  subjects  covers  the  opening  of  the  lachrymal  canals  into  the 
sac,"  is  apt  to  become  closed  from  the  long-continued  pressure  of 
a  foreign  substance.  Should  the  valve  be  shut,  it  must  be  forced 
open  by  the  Anelian  probe  passed  through  the  canals. 

The  wound  of  the  sac  is  now  to  be  dressed  once  a  day  with 
plain  Unt.  The  coloured  fluid  is  to  be  daily  injected.  If  for  four- 
teen days  successively  it  flows  in  a  full  stream  from  the  nose,  we 
proceed  to  close  the  wound.  We  make  its  edges  somewhat  raw 
with  the  lancet,  and  then  bring  them  together  with  adhesive  plaster. 

Second  Case.  As  soon  as  we  find  that  the  silver  probe  slicks 
fast  in  the  duct,  we  leave  it  there  till  the  next  day,  fastening  it  to 
the  forehead  by  a  proper  bandage,  closing  the  opening  of  the  sac 
with  a  little  lint,  and  applying  over  the  hnt  a  piece  of  court-plaster. 
For  a  week,  we  ought  not  to  despair  of  overcoming  the  obstruction, 
not  by  main  force,  but  by  gentle  and  daily  repeated  endeavours  to 
^et  the  probe  a  little  and  a  little  farther  through  the  duct,  turning 
:he  instrument  on  its  axis  at  every  trial,  and  varying  the  direction 
Df  the  pressure.  If  we  succeed  in  this  manner,  we  continue  the 
.reatment  as  has  been  explained  under  the  first  case.  If  we  fail, 
this  second  case  must  be  treated  as  the  third. 

Third  Case.  Two  causes  may  conspire  to  the  obliteration  of  any 
mucous  canal.  The  one  is  when  the  substance  of  the  tube  becomes 
violently  inflamed,  and  consequently  extremely  swoln :  the  other 
when  the  matter  of  secretion  or  of  excretion,  which  in  the  natural 
state  of  things  is  constantly  or  frequently  moving  through  the 
lanal,  ceases  any  longer  to  pass.  When,  for  instance,  a  portion 
af  the  substance  of  the  urethra  is  inflamed,  its  caliber  becomes 
much  contracted  in  consequence  of  the  tumefection  of  the  parietes 
dF  the  canal,  and  this  contraction  frequently  remains  permanent 
onder  the  name  of  stricture,  after  the  inflammation  has  subsided. 
SThere  are  two  causes  why  the  contraction  is  not  so  great  in  this 
;5ase  as  to  close  the  urethra  completely,  namely,  the  considerable 
j  size  of  the  canal,  and  the  frequent  and  forcible  passage  of  the  urine. 
[Let  a  small  canal,  such  as  the  nasal  duct,  be  inflamed  to  the  same 

['  *  RosenmUUer,  Partium  Externarum  Oculi  Humani  Descriptio.  §  125.  Lipsiae, 
11810.  if  if      > 


200 

degree,  and  let  no  secreted  fluid  be  pushed  violently  through  it, 
let  even  the  secretion,  which  in  health  slowly  drops  along  its  in- 
ternal surface  cease,  and  then  it  is  httle  to  be  wondered  at,  if  it 
come  at  last  to  be  completely  closed.  x\s  soon  as  a  mucous  canal 
ceases  to  be  employed  in  the  discharge  of  its  functions,  it  begins  to 
contract.  If  a  man  have  a  false  passage  from  the  urethra,  through 
which  the  mine  is  entirely  discharged,  three  inches  behind  the 
glans  penis,  the  three  inches  anterior  to  the  false  passage  being  no 
longer  in  use,  gradually  contract,  so  that  any  appearance  of  a  canal 
is  distinguished  with  difficulty.  The  apphcation  of  this  to  the  nasal 
duct  is  obvious. 

I  do  not  mean  to  assert,  that  the  obliteration  of  the  nasal  duct, 
is,  in  every  case,  the  consequence  either  of  tumefaction  of  its  parie- 
tes,  or  of  contraction  from  disuse.  When  the  mucous  membrane 
of  this  canal  becomes  ulcerated  or  excoriated,  as  I  have  no  doubt 
it  occasionally  does  in  the  course  of  inflammation,  an  effusion  of 
coagulable  lymph,  and  a  consequent  adhesion  between  the  sides 
of  the  duct,  may  give  rise  to  the  very  worst  variety  of  obhteration. 

If  in  our  examination  of  the  nasa.!  duct  we  have  discovered  that 
part  of  its  extent  is  obliterated,  recourse  is  to  be  had  to  perforation 
by  means  of  a  small  triangular  or  trocar-shaped  probe.  If  the  ex- 
tent of  the  obliteration  be  inconsiderable,  and  placed  consequently 
near  the  opening  of  the  duct  into  the  nose,  this  perforation  may  be 
performed  with  confident  hope  of  success.  A  few  drops  of  blood 
flow  from  the  nose  as  soon  as  the  perforation  is  completed.  The 
probe  is  immediately  to  be  withdrawn,  and  a  small  silver  style 
introduced.  This  remains  for  a  day  or  two,  and  then  the  very 
gradual  dilatation  of  the  duct,  which  has  already  been  described, 
is  to  be  commenced. 

If  a  considerable  portion  of  the  duct,  or  even  its  whole  extent, 
be  obliterated,  the  same  operation  ought  to  be  performed.  This  is 
done  with  at  least  equal  hopes  of  success  as  if  we  perforated  the  os 
unguis.  It  is  true,  that  nature,  constantly  tending  to  destroy  every 
thing  contrary  to  the  organic  system  which  she  has  adopted,  would 
probably  close  the  new  passage,  after  our  dilating  instruments  were 
laid  aside.  This  is  the  only  case,  then,  in  which  the  introduction 
of  a  metallic  tube  into  the  duct,  to  be  left  for  life,  is  at  all  defensible. 
A  gold  or  silver  tube,  not  more  than  an  inch  in  length,  and  pre- 
senting an  elevated  ring  surrounding  the  middle  of  its  external 
surface,  may  be  pushed  down  into  the  dilated  passage  which  we 
have  formed.  The  surrounding  substance  will  probably  contract 
upon  this  tube,  and  render  it  less  liable  to  be  displaced,  than  a 
similar  instrument  passed  into  the  natural  caliber  of  the  duct. 

The  tube  employed  ought  to  be  slightly  curved  inwards  and 
backwards,  so  as  to  correspond  to  the  form  of  the  parts  into  which 
it  is  to  be  introduced.  The  pewter  tubes  sold  in  the  shops  are  toe 
straight  and  thick.  On  trying  one  of  them  on  the  dried  craniun] 
of  an  adult  subject,  I  find  that  it  cannot  be  pushed  down  even  mh 


1 


201 

the  osseous  canal  through  which  the  nasal  duct  passes,  without 
fracturing  the  os  unguis. 

When  a  tube  is  passed  into  the  lachrymal  passage,  a  practice 
which  no  one  who  considers  with  attention  Mr.  Ware's  candid  ac- 
count of  it,*  will  ever  adopt,  except  in  the  case  of  obliterated  nasal 
duct,  it  may  be  questioned,  whether  the  tears  actually  flow  through 
the  metallic  canal,  or  descend  merely  on  the  outside  of  the  tube, 
as  they  do  along  the  surface  of  a  style,  and  whether  a  style  worn 
for  life  would  not  answer  the  purpose  just  as  well  as,  or  better  than, 
a  tube. 

It  has  often  occurred  to  me,  that  in  cases  of  strictured  or  obliterated 
nasal  duct,  recourse  might  be  had  with  advantage  to  the  use  of  a 
small  bougie,  armed  in  the  common  way  with  lunar  caustic.  This 
might  be  applied  from  time  to  time,  exactly  as  we  employ  the 
same  means  in  stricture  of  the  urethra,  introducing  the  bougie  from 
the  lachrymal  sac  down  into  contact  with  the  strictured  or  oblitera- 
ted part  of  the  duct,  keeping  it  there  for  the  space  of  two  or  three 
minutes,  and  after  withdrawing  it,  injecting  the  duct  with  tepid 
water.  Both  in  Germany  and  in  France,  a  similar  plan  has  been 
employed  with  success.! 

There  are  two  causes  of  obstructed  nasal  duct  which  I  must 
notice  before  leaving  this  subject. 

The  one  is  lachrymal  calculus  in  the  duct.  Dr.  Krimer  relates 
the  case  of  a  woman,  aged  32,  who  for  nine  months  had  been  affected 
with  disease  of  the  excreting  lachrymal  organs.  The  sac  was  swelled, 
hard,  and  upon  the  most  prominent  part  of  the  tumour,  which  was 
red  and  painful,  there  was  a  small  ulcer  which  penetrated  into  the 
sac,  and  discharged  pus,  mixed  with  tears,  especially  on  pressure. 
The  nasal  duct  appeared  entirely  obliterated,  for  the  finest  sound 
could  not  be  introduced  a  line  within  it.  When  Dr.  K.,  in  order 
to  re-establish  the  duct,  endeavoured  to  introduce  a  pointed  probe,  he 
withdrew  on  its  extremity  a  strong  concretion  of  the  size  of  a  small 
pea,  the  removal  of  which  left  the  canal  entirely  free,  and  the 
fistula  was  promptly  cured.  The  calculus  was  ash-gray,  covered 
with  thick  mucus,  polished,  of  a  calcareous  appearance,  and  insolu- 
ble in  water,  alcohol,  and  weak  vinegar.  Dr.  K.  thinks  that  it 
was  formed  in  the  lachrymal  sac,  by  inspissated  mucus.i 

The  other  cause  of  obstructed  nasal  duct  is  of  a  more  formidable 
nature,  namely,  exostosis  of  the  osseous  passage  through  which 
the  duct  descends.  "  I  have  often  found,"  says  Mr.  Travers,  "the 
canal  completely  obliterated  by  ossific  inflammation  at  its  upper 
orifice  in  skulls."  §     I  have  met  with  one  case  of  this   kind  on 

*  See  Ware's  Observations  on  the  Treatment  of  the  Fistula  Lachrymalis,  p.  79. 
London, 1818. 

t  See  a  paper  by  Dr.  Harveng,  of  Manheim,  in  the  Archives  Gcnerales  de  Med- 
ecine,  Tome  xviii.  p.  48.     Paris,  1828. 

t  Dr.  Krimer's  case  was  originally  published  in  Grafe  and  Walther's  Journal.  I 
have  quoted  it  from  the  American  Journal  of  the  Medical  Sciences,  vol.  iii.  p.  216. 
Philadelphia,  1828.       §  Synopsis  of  the  Diseases  of  the  Eye,  p.  243.    London,  1820. 

26 


202 

dissection,  and  what  is  worthy  of  remark,  the  individual,  as  fai 
as  I  could  learn,  had  not  been  much,  if  at  all,  troubled  with  stilli- 
cidium  lachrymarum. 

If  no  passage  is  obtained  for  the  tears  and  mucus  from  the  sb 
into  the  nostril,  the  patient  will  be  exposed  to  perpetual  attacks 
inflammation  in  the  sac,  which  will  give  rise  to  much  distres 
and  to  the  formation  of  fistulse.  In  such  a  case,  I  have  seen  at 
tempts  made  to  obliterate  the  sac,  by  laying  it  completely  opei 
and  dressing  it  with  escharotics.  It  is  much  more  difiicult  to  ob-' 
literate  the  sac  in  this  case,  than  in  that  which  I  have  described 
at  page  195.  Indeed,  the  obhteration  will  not  be  obtained,  unless 
we  manage  permanently  to  close  the  apertures  of  the  lachrymal 
canals  into  the  sac.  If  these  remain  patent,  they  will  gradually 
re-dilate  the  sac.  I  have  already  had  occasion  to  refer  to  a  case  ic 
w^hich  the  osseous  tube  for  conveying  the  nasal  duct  was  obliter- : 
ated,  in  consequence  of  a  kick  from  a  horse,  which  had  shatterec 
and  bent  in  the  upper  maxillary  bone.  As  it  was  found  impossible 
in  this  case  to  effect  any  new  passage  for  the  tears,  not  ever 
through  the  os  vmguis,  attempts  w^ere  made,  by  caustics  of  various 
kinds,  and  even  by  the  actual  cautery,  to  obhterate  the  sac  and 
lachrymal  canals,  but  without  success. 


CHAPTER  VII. 

DISEASES  OP  THE  MUSCLES  OF  THE  EYEBALL. 

SECTION  I. INJURIES    OF    THE    MUSCLES    OF    THE    EYEBALL^j 

Injuries  of  the  muscles  of  the  eyeball  are  extremely  rare.  Th^ 
obliqui  are  more  exposed  than  the  recti.  The  looseness  of  the  or- 
bital cellular  membrane  serves  to  save,  in  many  cases  of  penetrating 
wound,  both  the  eyeball  and  its  muscles.  The  recti  are  farther 
protected  by  their  position  behind  the  eyeball,  while  the  branches 
of  the  third  pair,  by  which  they  are  supplied  with  nervous  energy, 
enter  their  substance  on  their  central  surface,  so  as  to  be  placed  as 
much  out  of  the  way  of  injury  as  possible.  Still  it  must  occasion- 
ally happen,  (in  such  wounds,  for  example,  as  have  been  described 
in  the  first  section  of  the  first  chapter,)  that  the  muscles  shall  sus- 
tain more  or  less  extensive  injury ;  and  the  consequence  will  be  a 
certain  degree  of  impediment  in  the  motions  of  the  eyeball. 

The  swelling  and  inflammation  which  ensue,  almost  immediate- 
ly, on  penetrating  wounds  of  the  orbit,  added  to  the  depth  of  the 
injured  parts,  will  in  general  render  it  impossible  to  determine  the 
amount,  or  perhaps  even  the  reality,  of  injury  done  in  such  cases  to 
the  muscles.     Nor  is  this  of  much  consequence  in  a  practical  point 


203 

of  view;    rest,  soothing  applications,   and  antiphlogistic  means, 
making  up  the  treatment  in  all  such  cases. 


SECTION  II. PALSY  OF    THE    MUSCLES    OF    THE    EYEBALL. 

I  have  already  had  occasion  to  refer  to  the  frequency  of  paralytic 
affections  of  the  muscles  supplied  by  the  third  nerve  or  motor  oculi.* 
Palsy  of  the  rectus  superior,  inferior,  and  internus,  accompanied  by 
la  similar  affection  of  the  levator  palpebree  superioris,  v^hile  the  rec- 
tus externus  retains  its  power,  and  turns  the  eyeball  permanently 
i  uowards  the  temple,  is  a  state  of  these  muscles  which  I  have  often 
had  an  opportunity  of  observing.  If  with  the  finger  we  lift  the 
I  upper  eyehd  in  such  a  case,  and  tell  the  patient  to  look  to  the 
ground,  we  see  that  he  attempts  to  do  so,  but  is  utterly  unable  to 
liccomplish  his  intention.  If  we  tell  him  to  look  upwards  or  in- 
ivards,  he  fails  in  both  ;  and  even  when  he  endeavours  to  look 
straight  forwards,  the  eye  is  scarcely,  if  at  all,  moved  from  its  po- 
Uition.t  In  some  rare  cases  it  happens,  that  after  this  paralytic 
J  state  of  the  muscles  supplied  by  the  third  pair  has  continued  for 
'  jome  time,  the  abductor  becomes  also  palsied,  so  that  the  eye  is  no 
longer  turned  towards  the  temple,  but  looks  directly  forwards,  and 
;an  be  moved  by  any  voluntary  effort  of  the  patient  neither  up- 
;vards,  downwards,  inwards,  nor  outwards.  We  may  conclude,  in 
mch  circumstances,  that  the  disease  which  originally  caused  pres- 
!  sure  on  the  third  pair  only^  has  extended  so  as  to  effect  the  sixth 
laair  also, 

While  the  motions  produced  by  the  recti  are  thus  partially  or  to- 
;ally  impeded,  the  involuntary  movement  upwards  of  the  eyeball, 
ivhich  takes  place  when  we  wink,  or  close  the  eyes  in  sleep,  and 
vhich  is  attributed  to  the  action  of  the  obliqui,  is  in  some  cases  re- 
gained, while  in  other  causes  this  motion  also  is  lost. 
■  We  generally  find,  in  cases  of  palsy  of  the  muscles  of  the  eye- 
ijall,  that  the  fifth  nerve  and  the  portio  dura  continue  to  exercise 
..heir  functions.  The  retina  also  retains  its  sentient  power,  at  least 
n  a  very  considerable  degree.  It  not  unfrequently  happens,  how- 
;  iver,  that  the  pupil  is  fixed  and  vision  somewhat  indistinct. 
!  Headach,  vertigo,  and  double-visioOj  generally  attend  attacks  of 
oalsy  of  the  muscles  of  the  eyeball.  The  stomach  and  bowels  are 
lilso  often  deranged. 

Causes.  As  I  have  already  hinted,  there  are  two  varieties  of  this 
palsy,  the  one  rheumatic,  and  the  other  cerebral.  The  former 
irises  from  exposure  to  cold,  while  the  cerebral  is  owing  either  to 
5udden  effusion,  or  slow  disorganization  within  the  cranium. 

Treahnent.  I  have  nothing  to  add  to  what  has  been  said  under 
ji^hia  head  at  page  143.  The  same  morbific  causes  being  in  opera- 
[tipn  must  be  combated  by  the  same  remedies.     In  rheumatic,  and 

'  •  See  page  143.  t  Luscitas, 


204 

sudden  cerebral  cases,  we  are  often  successful  by  merns  of  deple- 
tion, counter-irritation,  sorbefaction,  &c.  while  in  the  lIow  cerebral 
cases,  we  are  too  often  but  mere  spectators  of  the  loss  of  one  func- 
tion after  another,  till  death  closes  the  scene. 


SECTION  III. DOUBLE    VISION  FROM  WANT  OF  CORRESPOND-    li 

ENCE  IN  THE  ACTION  OF  THE  MUSCLES  OF  THE  EYEBALL. 

In  strabismus,  there  is  a  want  of  correspondence  in  the  actions 
of  the  muscles  of  the  eyeball,  and  at  the  commencement  of  the 
complaint,  there  is  double  vision  ;  but  it  would  appear,  that  double 
vision  occasionally  occurs  with  so  very  slight  a  degree  of  distortion 
of  the  eyes,  as  scarcely  to  be  observable.  The  double  vision  to 
which  I  refer,  takes  its  origin,  at  least  in  some  cases,  from  over- 
exertion of  the  eyes,  and  is  an  affection  of  the  muscles  of  the  eye- 
ball. It  is  of  importance  to  be  aware  of  the  existence  of  cases  ol 
this  kind,  lest  we  should  confound  them  with  those  in  which  double 
vision  is  owing  to  an  affection  of  the  brain,  or  of  the  optic  nerve. 

Sir  Everard  Home,  who  first  pointed  out  the  practical  importance 
of  this  distinction,  has  related  two  cases  as  illustrative  of  the  symp- 
toms and  treatment  of  the  subject  of  this  section.  The  cases  are 
interesting  in  several  respects,  although  it  must  be  confessed  that 
there  is  no  very  conclusive  evidence  to  prove  that  the  symptoms 
were  dependent  merely  on  an  affection  of  the  muscles  of  the  eye- 
ball, and  not  on  the  state  of  the  brain. 

The  first  case  which  led  him  to  pay  attention  to  the  subject,  was 
that  of  a  lieutenant-colonel  of  engineers,  who  was  in  perfect  health, 
shooting  moor-game  upon  his  own  estate  in  Scotland.  He  was 
very  much  surprised  towards  the  evening  of  a  fatiguing  day's  sport, 
to  find  all  at  once  that  every  thing  appeared  double ;  his  gun,  his 
horse,  and  the  road,  were  all  double.  This  appearance  distressed 
him  exceedingly,  and  he  became  alarmed  lest  he  should  not  find 
his  way  home ;  in  this,  however,  he  succeeded,  by  giving  the  reins 
to  his  horse.  After  a  night's  rest  the  double  vision  was  very  much 
gone  off;  and  in  two  or  three  days  he  went  again  to  the  moors, 
when  his  complaint  returned  in  a  more  violent  degree.  He  went 
to  Edinburgh  for  the  benefit  of  medical  advice.  The  disease  was 
referred  to  the  eye  itself,  and  treated  accordingly ;  the  head  was 
shaved,  blistered,  and  bled  with  leeches.  He  was  put  under  a 
course  of  mercury,  and  kept  upon  a  very  spare  diet.  This  plan 
was  found  to  aggravate  the  symptoms  ;  he  therefore,  after  giving  il 
a  sufiicient  trial,  returned  home  in  despair,  and  shut  himself  up  in 
his  own  house.  He  gradually  left  off  all  medicine,  and  Hved  as 
usual.  His  sight  was  during  the  whole  time  perfectly  clear,  and 
at  the  same  time  near  objects  appeared  single ;  at  three  yards  they 
became  double,  and  by  increasing  the  distance,  they  separated  farther 
from  each  other.    When  he  looked  at  an  object,  it  was  perceived  by  a 


I 


205 

by-stander,  that  the  two  eyes  were  not  equally  directed  to  it.  The 
complaint  was  most  violent  in  the  morning,  and  became  better 
after  dinner,  when  he  had  drank  a  few  glasses  of  wine.  It  con- 
tinued for  nearly  a  twelvemonth,  and  gradually  went  off. 

Sometime  after  the  recovery  of  this  gentleman,  a  house  painter, 
who  had  worked  a  good  deal  in  white  lead,  was  admitted  a  patient 
into  St.  George's  Hospital,  on  account  of  a  fever,  attended  with 
violent  headach.  Upon  recovering  from  the  fever,  he  was  very 
much  distressed  at  seeing  every  thing  double  ;  and  as  the  fever  was 
entirely  gone,  he  was  put  under  Sir  Everard's  care  for  this  affection 
of  his  eyes.  Upon  inquiring  into  his  complaints.  Sir  E.  found  them 
to  correspond  exactly  with  those  of  the  former  case,  and  therefore 
treated  them  as  arising  entirely  from  an  affection  of  the  muscles. 
He  bound  up  one  eye,  and  left  the  other  open.  The  patient  now  saw 
objects  single  and  very  distinctly,  but  looking  at  them  gave  him 
pain  in  the  eye,  and  brought  on  headach.  This  led  Sir  E.  to  be- 
lieve he  had  erroneously  tied  up  the  sound  eye ;  the  bandage  was 
therefore  removed  to  the  other,  and  that  which  had  been  bound  up 
was  left  open.  He  now  saw  objects  without  pain  or  the  smallest 
uneasiness.  He  was  thus  kept  with  one  eye  confined  for  a  week, 
after  which  the  bandage  was  laid  aside ;  the  disease  proved  to  be 
entirely  gone,  nor  did  it  return  in  the  smallest  degree  while  he 
remained  in  the  hospital.  Rest  alone  had  been  sufficient  to  allow 
the  muscles  to  recover  their  strength,  and  thus  to  produce  a  cure. 

Sir  Everard  concludes  by  observing,  that  when  muscles  are 
strained  or  over-fatigued,  to  put  them  in  an  easy  state,  and  confine 
them  from  motion,  is  the  first  object  of  attention,  and  that  this  prac- 
tice is  no  less  applicable  to  the  muscles  of  the  eye,  than  to  those  of 
other  parts.* 


SECTION    IV. STRABISMUS. 

Symptoms.  In  this  disease,  although  the  patient  means  to  look 
at  the  same  object  with  both  eyes,  one  of  them,  moving  involun- 
tarily, and  independently  of  the  motions  of  the  sound  eye,  turns 
away  from  its  natural  directions.  If  the  sound  eye  is  now  closed, 
the  other  generally  returns  to  the  proper  position,  and  so  long  as  it 
is  used  alone,  can  be  carried  by  the  will  of  the  patient  in  any  di- 
rection he  pleases.  The  instant,  however,  that  the  sound  eye  is 
again  opened,  the  one  affected  with  strabismus  revolves  inwards  or 
outwards,  and  there  it  remains,  not  harmonizing  in  the  movements 
of  its  fellow,  or  if  it  does  move  along  with  the  sound  eye,  yet  never 
so  as  to  permit  the  two  axes  to  15e  pointed  at  the  same  object. 
Hence  the  patient  sees  double,  especially  in  the  commencement 
of  this  disease ;  but  after  it  has  continued  for  a  length  of  time,  the 
double  vision  wears  off 

*  Philosophical  Transactions  for  1797,  Part  I.  p.  7. 


206 

The  eye  is  much  more  frequently  distorted  inwards  than  out- 
wards in  this  disease.  The  former  case  is  termed  strabismus  con- 
vergens,  and  the  latter  divergens.  In  some  individuals,  we  find 
the  eyes  to  squint  alternately,  or  even  both  together. 

The  vision  of  an  eye  that  squints  is  almost  always  imperfect ; 
and,  of  course,  those  who  squint  with  both  eyes,  see  indistinctly 
and  confusedly.  Those  who  squint  inwards  with  both  are  gen- 
erally very  short-sighted. 

Causes.  Strabismus  is  connected  with  many  remote  causes, 
each  of  which  may  be  regarded  as  giving  rise  to  a  different  variety 
of  the  disease. 

1.  Strabismus  appears  to  take  its  origin,  in  many  cases,  from 
improper  education  of  the  eyes  in  young  children.  In  all  new- 
born children,  there  is  a  great  mobility  and  restlessness  of  the  eyes, 
an  uncertainty  with  which  they  fix  their  eyes  on  objects,  and  not 
unfrequently  a  degree  even  of  strabismus.  Their  eyes  must  be 
educated  to  regular  and  harmonious  movement,  by  exposing  them 
equally  to  the  light,  and  presenting  to  their  view  objects  likely  to 
fix  their  attention,  neither  too  near  nor  at  too  great  a  distance,  and  - 
much  less  in  any  unnatural  direction.  Any  of  these  errors  appears 
capable  of  inducing  strabismus.  For  example,  this  disease  is  oc- 
casionally to  be  attributed  to  the  bad  custom  which  nurses  some- 
times have  of  laying  a  child  in  such  a  position  in  its  cradle,  that  it 
sees  the  light,  or  any  other  remarkable  object,  with  one  eye  only. 

or  of  holding  the  child's  toy  too  near  its  eyes,  and  of  amusing  it     j 
by  suddenly  presenting  some    favourite    object  close  to  its  face.     | 
Strabismus  divergens  is  attributed  to  the  improper  practice  of  ac-     i 
customing  a  child  to  look  at  the  same  time  at  two  objects  of  which 
it  is  fond,  but  which  are  distant  from  one  another.     The  child 
lying  in  its  cradle,  for  example,  with  the  window  on  one  side  and 
the  nurse  on  the  other,  instead  of  alternately  directing  its  eyes  to 
these  two  objects,  may  get  into  the  habit  of  distorting  one  of  the    ■ 
eyes  in  order  to  see  both  of  them  at  once.  * 

2.  Children  occasionally  become    squinters  from   a  fashion  of 
looking  at  the  point  of  their  nose,  or  if  there  be  any  wart  or  spot    t 
upon  it,  by  attempting  frequently  to  inspect  this  deformity.     They    \ 
thus  distort  the  eyes,  and  fall  into  the  habit  of  doing  so  uncon- 
sciously. 

3.  Imitation  has  been  accused  as  a  cause  of  squinting. 

4.  Darwin  was  of  opinion,  that  the  most  general  cause  of  squint- 
ing in  children  was  the  custom  of  covering  a  weak  eye,  which  had 
become  diseased  by  any  accidental  cause,  before  the  habit  of  ob- 
serving objects  with  both  eyes  was  perfectly  estabUshed. 

5.  Strabismus  is  sometimes  attributed  to  spasm  of  one  of  the 
recti,  and  this  spasm  is  in  its  turn  supposed  to  arise  from  a  variety 
of  causes,  as  terror  from  a  puncture  of  the  eye,  &c.  I  was  con- 
sulted by  the  friends  of  a  little  boy,  who  became  affected  wdth 
strabismus  immediately  after  squirting  the  oily  juice  of  a  piece  of 
orange  skin  into  his  eye,  which  produced  a  great  degree  of  pain. 


207 

6.  A  speck  on  the  cornea  is  a  frequent  cause  of  squinting.  By 
turning"  the  eye  out  of  the  natural  axis  of  vision,  the  patient  is  able 
to  see  better  past  the  speck.  He  is  very  apt  so  to  turn  the  eye 
with  the  speck,  if  it  happens  to  be  the  better  eye  of  the  two.  In 
this  way  strabismus  is  not  an  unfrequent  consequence  of  strumous 
ophthahnia. 

7.  The  most  frequent  cause  of  strabismus  appears  to  be  imper- 
fect vision  from  short-sightedness,  or  from  congenital  defect  of  the 
retina.  The  distorted  eye,  in  almost  every  case,  is  very  consid- 
erably inferior  in  its  power  of  sensation  to  the  other.  I  use  the 
words  very  considerably^  because  we  meet  with  many  individuals 
who  have  the  eyes  slightly  unequal,  who  do  not  squint,  and  with 
others  who  have  laboured  from  birth  under  complete,  or  almost 
complete  amaurosis  of  one  eye,  and  yet  are  quite  free  from  stra- 
bismus. Buffon  considered  the  inequality  which  produced  stra- 
bismus as  averaging  3-8ths.  The  impression,  then,  on  the  one 
eye,  being  considerably  weaker,  than  that  on  the  other,  is  very 
liable  to  be  neglected  altogether,  and  that  eye,  instead  of  being 
fixed  on  the  objects  before  it,  is  left  to  wander  from  the  true  axis 
of  vision.  There  seems  even  to  be  an  instinctive  attempt,  in  some 
cases,  still  farther  to  distort  the  weak  eye,  and  to  turn  it  so  far  in- 
ward, and  under  the  upper  lid,  that  no  impression  can  be  received 
upon  it,  but  that  the  sound  eye  only  shall  become  the  instrument 
of  sensation. 

8.  Strabismus  is  induced  by  various  diseases  of  the  brain,  as 
apoplexy,  epilepsy,  hydrocephalus,  cerebral  irritation  from  worms, 
or  from  teething,  &c.  Amaurosis,  affecting  both  eyes,  is  generally 
attended  by  a  shght  degree  of  strabismus. 

9.  Whatever  be  the  remote  cause  of  strabismus,  we  cannot  doubt 
that  its  proximate  cause  must  in  some  way  or  other  affect  the  mus- 
cles of  the  eyeball.  One  or  more  of  these  muscles  must  be  in  a 
3tate  rendering  them  incapable  of  their  natural  exercise.  The 
muscular  substance  may  be  in  a  state  of  atony,  or  the  nervous  ener- 
gy which  ought  to  animate  them,  may  be  imperfectly  supplied.  In 
by  far  the  greater  number  of  cases  of  strabismus,  the  eye  rolls  in- 
voluntarily inwards,  which  may  lead  us  to  conclude,  that  the  ab- 
ductor is  in  a  state  of  unfitness  for  its  office.  It  is  not  absolutely 
paralyzed,  for  on  closing  the  sound  eye,  it  evidently  exerts  its  proper 
function,  but  from  some  cause  to  us  unknown,  as  soon  as  the  sound 
eye  is  again  opened,  the  muscular  force  of  the  abductor  is  no  longer 
able  to  support  the  eye  in  its  natural  direction,  so  that  the  distortion 
immediately  returns. 

Treatment.  1.  Our  first  object  in  the  treatment  of  strabismus, 
must  be  to  discover  the  cause.  When  this  is  accomplished,  the  plan 
of  cure  will  be  obvious  ;  or,  perhaps,  we  shall  find  reason  to  consider 
the  defect  as  irremediable. 

i     2.  As  strabismus  often  arises  in  children  from  abdominal  irrita- 
jytion,  we  ought  first  to  try  the  effect  of  an  active  purge  or  two  ;  and 


208 

then  follow  this  up  by  mild  aperients,  and  a  carefully  regulated  diet. 
Squinting  children  are  generally  weakly,  and  often  strumous,  so  that 
a  course  of  tonic  medicine  will  probably  be  useful. 

3.  Strabismus  is  frequently  observed  in  children  to  be  connected 
with  a  careless  employment  of  the  eyes,  which  is  instantly  corrected 
by  exciting  their  attention.  In  other  cases,  the  squint  is  never  ob- 
served except  when  the  child  is  in  bad  temper. 

4,  When  only  one  eye  squints,  and  when  the  defect  in  the  sight 
of  that  eye  is  not  very  great,  much  may  be  done,  by  strengthening 
its  muscles,  to  cure  the  strabismus.  The  strengthening  of  the  mus- 
cles is  effected  chiefly  by  tying  up  the  sound  eye,  and  thus 
obhging  the  patient  to  exercise  only  the  eye  v^^hich  squints. 
Whenever  the  sound  eye  is  bUnd-folded,  the  weak  eye  recovers  its 
natural  position  in  the  orbit,  and  its  natural  motions.  The  patient 
finds  that  the  sight  gradually  improves  by  use  ;  and  we  observe  that 
though  the  strabismns  does  return,  on  again  exposing  the  sound 
eye,  yet  it  is  not  to  the  same  extent,  and  day  after  day  becomes 
less,  if  the  plan  of  cure  is  continued. 

The  patient  need  not  keep  the  sound  eye  covered  during  the 
whole  day.  At  first,  this  may  be  done  for  half  an  hour  or  an  hour 
at  a  time,  and  then  for  longer  periods.  During  the  blindfolding  of 
the  sound  eye,  the  -weak  one  is  to  be  exercised  both  on  distant  and 
on  near  objects,  but  especially  on  the  former.  If  the  patient  be  a 
child,  he  must  be  encouraged  to  exercise  the  weak  eye  in  playing 
at  ball  or  shuttlecock,  viewing  extensive  prospects  in  the  countr}', 
reading  books  printed  in  a  large  type,  looking  at  prints,  &c.  Many 
authorities  might  be  produced  in  favour  of  the  efiicaciousness  of  this 
mode  of  cure.  Beer  tells  us,  that  by  binding  up  the  sound  eye 
every  day  even  for  a  couple  of  hours  only,  he  had,  in  most  cases, 
been  successful.*  It  is  worthy  of  remark,  however,  that  this  plan 
of  curing  strabismus  is  often  attended  by  a  diminished  power  both 
of  motion  and  of  vision  in  the  sound  eye  ;  and  that  it  has  some- 
times happened,  that  the  squinting  eye  being  cured  by  perseverance 
in  this  method,  the  sound  eye  has  then  become  distorted.  If  both 
eyes  squint  from  the  first,  they  must  be  bUudfolded  alternately,  each 
for  several  days  at  a  time. 

Another  method  of  exercising  the  weak  e)'e  is  that  recommended 
by  Dr.  Jurin,  in  his  Essay  on  Distinct  and  Indistinct  Vision.  Hav- 
ing placed  the  patient  before  us,  we  bid  him  close  the  undistorted 
eye,  and  look  at  us  with  the  other.  When  we  find  the  axis  of  this 
eye  fixed  directly  upon  us,  we  bid  him  endeavour  to  keep  it  in  that 
situation,  and  open  his  other  eye.  Immediately,  the  distorted  eye 
turns  away  from  us  towards  his  nose,  and  the  axis  of  the  other  is 
pointed  at  us.  But  with  patience  and  repeated  trials,  he  will,  by 
degrees,  be  able  to  keep  the  distorted  eye  fixed  upon  us,  at  least  for 
some  little  time  after  the  other  is  opened.     When  we  have  brought 

*  Pflege  gesunder  und  geschwachter  Augen.  p.  41.    Frankfurt,  1803. 


209 

him  to  continue  the  axes,  of  both  eyes  fixed  upon  us,  as  we  stand 
directly  before  him,  it  will  be  time  to  change  his  position,  and  to 
set  him  first  a  little  to  one  side  of  us  and  then  to  the  other,  and  so 
to  practise  the  same  thing.  When,  in  all  these  situations,  he  can 
perfectly  and  readily  turn  the  axes  of  both  eyes  towards  us,  the  cure 
is  effected.  An  adult  may  practise  all  this  in  a  mirror,  without  any 
director,  though  not  so  easily  as  with  one. 

5.  As  there  is  an  inequality  in  the  sensations  of  the  sound  and 
of  the  weak  eye,  it  has  been  suggested  that  we  should  endeavour 
to  render  them  more  on  a  par,  and  that  this  of  itself  would  tend 
to  correct  the  distortion.  Buffon  recommended,  therefore,  that 
the  patient  should  wear  a  pair  of  spectacles  with  a  plane  glass  op- 
posite to  the  bad  eye,  and  a  convex  glass  opposite  to  the  good  eye. 
In  this  way,  the  vision  of  the  good  eye  would  be  rendered  less 
distinct,  and  consequently  it  would  be  less  in  a  state  to  act  inde- 
pendently of  the  other.*  As  the  weak  eye  is  often  short-sighted, 
the  same  advantage  might  perhaps  be  derived  from  placing  a  plane 
glass  before  the  good  eye,  and  a  concave  glass  before  the  distorted 
one. 

6.  The  treatment  of  strabismus  will,  of  course,  be  varied,  ac- 
cording as  the  cause  is  more  or  less  intimately  connected  with  the 
muscles  of  the  eyeball.  A  mere  bad  habit  in  the  use  of  these 
muscles  will  probably  be  completely  overcome  by  the  first  two 
means.  In  cases  of  speck  of  the  cornea,  short-sightedness,  partial 
amaurosis,  disease  within  the  cranium,  nervous  irritation  commu- 
nicated from  distant  organs,  means  suited  to  these  different  causes 
must  be  adopted.  In  some  cases,  a  certain  degree  of  success  ob- 
tained by  one  plan  must  be  followed  up  by  another  of  a  totally" 
different  kind.  Thus,  Pellier  relates  the  case  of  a  girl  whose 
squint  was  occasioned  by  a  speck  on  the  cornea  consequent  to 
small-pox.  By  the  use  of  stimulating  drops,  he  removed  the  speck, 
but  the  strabismus  remained  the  same.  He  then  began  a  careful 
system  of  exercise,  with  the  sound  eye  covered,  and  by  this  means 
effected  a  cure.t 

7.  In  cases  of  strabismus  convergens,  affecting  both  eyes,  it  is 
recommended  that  a  pair  of  blinders,  projecting  in  front  of  the 
temples,  should  be  tried,  during  at  least  a  portion  of  every  day, 
with  the  view  of  attracting  the  eyes  outwards  ;  and  that  when  the 
blinders  are  laid  aside,  a  broad  green  shade  should  be  worn. 

Darwin  employed  a  different  plan,  and  with  considerable  suc- 
cess, in  a  case  which  appears  to  have  partaken  of  the  nature  of 
this  strabismus,  and  which  he  has  related  in  the  Philosophical 
Transactions.  The  patient  was  a  child,  of  5  years  of  age,  exceed- 
ingly tractable  and  sensible.  He  viewed  every  object  which  was  pre- 
sented to  him  with  but  one  eye  at  a  time.  If  the  object  was  present- 

*  Dissertation  sur  la  Cause  du  Strabisnoe.     Memoires  de  I'Academie  des  Sciences 
pour  1743,  p.  338.     12mo.     Amsterdam,  1748. 
t  Recueil  de  Memoires  et  d' Observations,  p.  410.    Montpellier,  1783. 


210 

ed  on  his  right  side,  he  viewed  it  with  his  left  eye,  and  vice  versa.  ■■ 
He  turned  the  pupil  of  that  eye,  which  was  on  the  same  side  with' 
the  object,  in  such  a  direction  that  the  image  of  the  object  might 
fall  on  that  part  of  the  bottom  of  the  eye  where  the  optic  nerve 
enters  it.  When  an  object  was  held  directly  before  him,  he 
turned  his  head  a  httle  to  one  side,  and  observed  it  with  but  on& 
eye,  viz.  with  that  most  distant  from  the  object,  turning  away  the 
other  in  the  manner  above  described  ;  and  when  he  became  tired 
with  observing  it  with  that  eye,  he  turned  his  head  the  contraryl 
"way,  and  observed  it  with  the  other  eye  alone,  with  equal  faciUty ; 
but  never  turned  the  axes  of  both  eyes  on  it  at  the  same  time. 
He  saw  and  named  letters,  with  equal  ease,  and  at  equal  distances,! 
with  the  one  eye  as  with  the  other.  There  was  no  perceptible 
difference  in  the  diameters  of  the  irises,  nor  in  their  contractihty/ 
after  having  covered  his  eyes  from  the  light.  From  these  circum- 
stances, Darwin  was  led  at  first  to  conclude  that  there  was  no  de- 
fect in  either  eye,*  but  that  the  disease  was  simply  a  depraved 
habit  of  moving  his  eyes,  which  might  probably  be  occasioned  by 
the  form  of  a  cap  or  head-dress,  which  might  have  been  too  prom- 
inent on  the  sides  of  his  face,  like  bluffs  used  on  coach-horses,  and 
might,  in  early  infancy,  have  made  it  more  convenient  for  the  child 
to  view  objects  placed  obUquely  with  the  opposite  eye,  till  by  habit 
tlie  adductores  were  become  stronger,  and  more  ready  for  motion 
than  their  antagonists.  Darwin  recommended  a  paper  gnomon  to 
be  made,  and  fixed  to  a  cap.  When  this  artificial  nose  was  placed 
over  his  real  nose,  so  as  to  project  an  inch  between  his  eyes,  the 
child,  rather  than  turn  his  head  so  far  to  look  at  oblique  objects, 
immediately  began  to  view  them  with  that  eye  which  was  next  to 
them.  The  plan  of  cure  was  not  persisted  in  ;  so  that,  six  years 
after,  Darwin  found  all  the  circumstances  of  this  child's  mode  oi 
vision  exactly  as  they  had  been,  except  that  they  seemed  estab- 
lished by  longer  habit,  so  that  he  could  not  bend  the  axes  of  both 
his  eyes,  on  the  same  object,  not  even  for  a  moment. 

By  Darwin's  advice,  a  gnomon  of  thin  brass  was  made  to  stand 
over  his  nose,  with  half  a  circle  of  the  same  metal  to  go  round  his 
temples.  These  w-ere  covered  with  black  silk,  and  by  means  of  a 
buckle  behind  his  head,  and  a  cross-piece  over  the  crown  of  his 
head,  this  gnomon  was  worn  without  inconvenience,  and  projected 
before  his  nose  about  two  inches  and  a  half.  By  the  intervention 
of  this  instrument,  he  soon  found  it  less  inconvenient  to  view  oblique 
objects  with  the  eye  next  to  them,  instead  of  the  eye  opposite  to 
them.  After  this  habit  was  weakened  by  a  week's  use  of  the 
gnomon,  two  bits  of  wood,  about  the  size  of  a  goose-quill,  black- 
ened all  but  a  quarter  of  an  inch  at  their  summits,  were  frequently 
presented  for  him  to  look  at,  one  being  held  on  one  side  the  ex- 

*  From  a  series  of  experiments  which  he  afterwards  made,  he  came  to  the  condu- 
sion  that  the  insensible  spot  at  the  bottom  of  this  child's  eye  was  four  times  the  arei 
of  that  in  the  eyes  of  others. 


.  211 

I 

tremity  of  the  gnomon,  and  the  other  on  the  other  side  of  it.  As 
he  viewed  these,  they  were  gradually  brought  forwards  beyond  the 
gnomon,  and  then  one  was  concealed  behind  the  other.  By  this 
means,  in  another  week,  he  could  bend  both  his  eyes  on  the  same 
object  for  half  a  minute  together.  By  the  practice  of  this  exercise, 
before  a  glass,  almost  every  hour  in  the  day,  he  became  in  another 
week  able  to  read  for  a  minute  together,  with  his  eyes  both  directed 
on  the  same  objects.  By  perseverance  in  the  use  of  the  artificial 
nose,  he  acquired  more  and  more  the  voluntary  power  of  directing 
both  eyes  to  the  same  object,  particularly  if  the  object  was  not  more 
than  four  or  five  feet  from  him,  so  that  Darwin  anticipated  a  com- 
plete cure.* 

i  8.  In  strabismus  divergens,  affecting  both  eyes,  the  alternate 
bUndfolding  of  the  eyes  is  as  likely  to  be  useful  as  in  the  conver- 
gens.     It  has  also  been  recommended  to  apply  a  piece  of  black 

s  plaster  on  the  point  of  the  nose,  which  may  attract  the  patient's 

;  view,  and  correct  the  divergence. 

Weller  recommends  a  short  funnel,  made  of  pasteboard,  with  an 

'oval  base,  to  be  so  applied  as  to  include  both  eyes,  and  having,  at 

ithat  part  which  rests  above  the  point  of  the  nose,  an  opening  about 
an  inch  in  diameter.  Through  this  instrument,  fixed  perfectly 
straight  and  firm,  the  patient  must  look,  and  by  and  by  read.     He 

;is  obliged,  by  this  contrivance,  when  he  wishes  to  see  or  to  read 

jany  thing,  to  turn  the  eyes  inwards  and  downwards.t 


|«ECTION    V. LUSCITAS,    OR    IMMOVABLE    DISTORTION    OP    THE 

1  EYEBALL. 

)      The  word  luscitas,  has  been  used  in  various  senses  by  authors 

oa.  the  diseases  of  the  eye.     Plenck  employs  it  as  synonymous  with 

)  oblique  vision,  or  that  state  of  the  eyes,  in  which  the  patient,  see- 

jing  little  or  nothing  when  he  looks  directly  forwards,  perceives  ob- 

jjects  situated  to  one  side,  but  without  any  distortion  of  the  eye  ;  t 

while  Beer  understands  by  luscitas,  that  the  eye  is  turned  to  one  or 

other  side,  and  is  there  completely  fixed,  so  that  the  patient  is  una- 

■  ble  to  move  it.§     Luscitas,  in  this  sense,  is  often  confounded  with 

! strabismus;  but  in  the  latter  affection,  the  patient  is  able  to  direct 

I  the  distorted  eye  upon  any  object  as  soon  as  he  closes  the  sound 

:  eye,  while,  to  effect  the  same  purpose  in  luscitas,  he  must  rotate 

[  the  head. 

I       *  Philosophical  Transactions  for  1778,  Vol.  Ixviii.  Part  i.  p.  86. 
'      t  Krankheiten  des  Menschlichen  Augen.  p.  234.     Berlin,  1819. 
i      i  Luscitas  sen  visus  obliquus  est  ocuh  vitium  quo  segrotus  objecta  non  directe  sed 
';  oblique  solummodo  \idere  potest.     Differt  luscus  a  strabone,  luscus  enim  oculum  non 
distorquet.     Doctrina  de  Morbis  Oculorum,  p.  214.     ViennsB,  1777. 
§  Der  Schiefsehende  vermag  es  aber  entweder  gar  nicht,  oder  nur  mit  sehr  grosser 
,  Beschwerde,  den  Augapfel  in  die  seiner  fehlerhaften  Stellung  entgegengesetzte  Rich- 
ii  tung  zu  bringen.    Lehre  von  den  Augenkrankheiten.    Vol.  ii.  p.  667.    Wein,  1817. 


212 

Causes.  Palsy  of  the  rectus  internus,  attended  generally  by  a 
similar  affection  of  the  rectus  superior,  rectus  inferior,  and  levator 
palpebree  superioris,  while  the  rectus  externus  retains  its  power,  and 
rolls  the  eye  outwards,  is  the  most  frequent  cause  of  immovable 
distortion.  Injuries  of  the  muscles  of  the  eyeball,  or  of  the  nerves, 
may  produce  a  similar  effect ;  also,  the  pressure  of  tumours  with- 
in the  orbit,  or  a  congenital  deficiency  of  one  of  the  recti. 

Treatment.  Luscitas  is  often  incurable.  The  turning  of  the 
eye  outwards,  in  palsy  of  the  muscles,  may  go  off,  the  eye  coming 
again  to  be  directed  forwards,  merely  in  consequence  of  the  palsy 
extending  to  the  rectus  externus.  Except  in  cases  of  injury  of  the 
muscles,  or  their  nerves,  and  of  orbital  tumours,  the  treatment  of 
luscitas  is  that  already  recommended  for  palsy  of  the  muscles  of  the 
eyeball. 


SECTION  VI. OSCILLATION  OF  THE  EYEBALL. 

Symptoms.  In  this  disease,  the  eyeball  is  affected  with  an  almost 
perpetual  semi-rotatory  motion,  round  its  antero-posterior  axis.  The 
patient  is  not  conscious  of  this  motion,  nor  can  he  restrain  it.  The 
motion  varies  in  extent,  from  a  scarcely  perceptible  degree,  to  as 
much  as  a  fourth  of  the  circumference  of  the  eyeball.  It  seems  to 
be  produced  by  the  antagonizing  action  of  the  obliqui,  the  recti 
having  lost,  in  a  great  measure,  their  control  over  the  eye.  Pa- 
tients affected  with  partial  amaurosis  often  complain  of  all  objects 
appearing  to  them  in  a  state  of  tremor,  but  this  does  not  seem  to 
depend  on  oscillation,  but  probably  arises  from  some  peculiar  mor- 
bid state  of  the  retina. 

Causes.  This  affection  frequently  attends  the  partial  amaurosis, 
which  in  many  cases  is  consequent  to  deep-seated  strumous  inflam- 
mation of  the  eyeball.  Congenital  cataract,  especially  if  of  some 
years'  standing,  is  always  attended  by  oscillation.  This  is  urged  as 
a  reason  for  operating  at  an  early  period  of  life  in  cases  of  that 
kind.  Fatiguing  employments  of  the  sight  always  increase  this 
unsteadiness  of  the  eyes ;  while  it  generally  subsides,  in  some  mea- 
sure, after  a  period  of  rest.  It  is  often  attended  by  short-sightedness, 
a  sense  of  weariness  in  the  eyes,  and  sometimes  by  pain  deep  in 
the  orbits  and  in  the  head. 

Treatm,ent.  Even  in  the  most  favourable  cases  of  oscillation 
attending  congenital  cataract,  this  symptom  diminishes  very  slowly 
after  the  pupils  become  clear,  from  the  removal  of  the  opaque  lens. 
If  partial  amaurosis  has  accompanied  the  cataract,  the  oscillation 
continues  unchanged.  In  cases  of  oscillation  attending  partial 
amaurosis,  and  accompanied  by  pain  deep  behind  the  eyes,  the 
occasional  application  of  leeches  to  the  temples  both  relieves  the 
pain,  and  lessens  the  oscillation.  Rest  of  the  eyes,  and  a  course  of 
tonic  medicines,  are  indicated  in  most  other  cases  of  oscillation ;, 
but,  it  must  be  confessed,  are  rarely  productive  of  a  permanent  and, 
complete  cure. 


213 


SECTION  VII. — NYSTAGMUS. 


This  term  is  used  to  signify  an  involuntary  motion  of  the  eyeball 
from  side  to  side.  It  is  a  clonic  convulsion  of  the  recti,  symptoma- 
tic of  various  nervous  diseases,  as  hysteria,  epilepsy,  chorea,  &c. 


SECTION  VIII. TETANUS  OCULI. 

A  fixed  state  of  the  eyeball,  from  tonic  spasm  of  all,  or  several  of 
•the  recti,  is  so  called. 


CHAPTER  VIII. 

DISEASES  IN  THE  ORBITAL  CELLULAR  MEMBRANE. 

SECTION  I. — INFLAMMATION  OF  THE  ORBITAL  CELLULAR 
MEMBRANE. 

The  fatty  cellular  membrane  which  envelopes  the  muscles  and 
nerves  of  the  orbit,  and  by  which  the  eyeball  is  supported,  is  sub- 
ject to  acute  phlegmonous  inflammation,  ending  in  suppuration, 
and  forming  one  of  the  most  severe  and  dangerous  affections  of  the 
organ  of  vision. 

Symptoms.  During  the  first,  or  purely  inflammatory  stage, 
pain  is  felt,  deep  in  the  orbit,  rapidly  increasing  in  severity,  and 
extending  to  the  forehead  and  temple.  The  eyeball  feels  as  if  con- 
stantly pressed  upon,  or  as  if  the  orbit  had  become  too  small  to 
contain  it.  The  pain  is  greatly  increased  by  touching  the  eye,  or 
attempting  to  move  it.  The  patient  is  distressed  by  the  sensation 
of  flashes  of  fire  in  the  eye.  Vision  soon  begins  to  fail,  from  the 
pressure  exercised  on  the  eyeball  by  the  inflamed  and  tumefied 
parts  by  which  it  is  surrounded,  from  the  inflammation  spreading 
to  the  optic  nerve  and  its  envelope,  and  from  the  nerve  being  put 
on  the  stretch  by  the  projection  of  the  eyeball  forwards  in  the  orbit. 
The  eye  is  soon  observed  to  be  more  prominent  than  natural.  The 
conjunctiva  becomes  red  and  chemosed.  The  pupil  is  contracted 
from  irritation,  and  in  some  cases  the  eyeball  partakes  in  the  in- 
flammation. This,  however,  is  by  no  means  constantly  the  case ; 
matter  may  even  form  behind  the  eye,  and  yet  its  proper  textures 
remain  apparently  uninjured.  When  they  do  inflame,  the  iris 
becomes  discoloured  and  motionless.  The  eyelids  are  red,  painful, 
and  swollen,  as  if  affected  with  erysipelas,  and  move  with  difficulty. 
,The  secretion  of  tears  is  soon  checked,  from  the  lachrymal  gland 
staking  part  in  the  inflammation,  but  till  then  there  is  epiphora. 


214 

The  symptoms  of  inflammatory  fever  attend  these  local  appear- 
ances. The  pulse  is  hard,  full  and  frequent.  The  face  is  flushed, 
The  patient  is  thirsty,  his  skin  hot,  he  rests  none,  and  is  often 
deUrious,  especially  during  the  night.  The  inflammation  may  . 
extend  to  the  membranes  and  substance  of  the  brain,  and  then  we 
have  all  the  usual  symptoms  of  phrenitis. 

In  the  second  stage,  matter  having  formed  behind,  or  to  one  side 
of  the  eyeball,  it  is  still  more  protruded,  and  is  more  or  less  distorted. 
It  is  sometimes  so  much  protruded,  as  to  project  beyond  the  eyelids, 
pushing  them  aside,  and  presenting  the  displacement  called  exoph- 
thalmos. The  matter  generally  presses  forwards  to  the  front  of 
the  orbit,  and  fluctuates  behind  the  conjunctiva,  or  between  the  edge 
of  the  orbit  and  one  or  other  of  the  eyelids.  In  some  cases,  there 
are  several  points  of  fluctuation.  If  there  is  only  one,  it  is  reasona- 
ble to  conclude,  that  suppuration  has  taken  place  only  on  one  side 
of  the  eye.  The  eyeball,  in  this  case,  is  thrown  forwards  in  an 
oblique  direction.  Not  unfrequently  the  eyeball  is  destroyed  by 
suppuration.  Matter  is  seen  to  be  lodged  behind  and  in  the  sub- 
stance of  the  cornea,  which  after  a  time  bursts,  and  allows  the  hu- 
mours to  be  evacuated.  The  photopsia  continues,  the  delirium  in- 
creases, the  pain  becomes  more  distinctly  pulsative,  and  is  of  agoniz- 
ing severity.  Vision  is  totally  destroyed.  Even,  when  the  eyeball 
has  not  suffered  much  in  texture  from  the  inflammation,  the  retina 
is  left  in  a  state  of  insensibility.  In  some  cases,  apoplectic  and  fa- 
tal symptoms  occur  before  the  abscess  is  so  much  distended  as  to 
point  externally.  Rigors  generally  attend  the  second  stage.  The 
pulse  falls  when  the  matter  first  begins  to  form,  but  rises  again 
when  the  abscess  becomes  distended. 

If  this  disease  be  neglected  or  mistreated,  the  inflammation  may 
spread  not  only  to  the  eyeball,  but  to  the  periosteum  and  bones  of 
the  orbit,  or  the  matter  may  make  its  way  into  the  nostril,  the  max- 
illary sinus,  or  even  the  cranium.* 

Although,  in  general,  inflammation  of  the  orbital  cellular  mem- 
brane is  an  acute  and  rapid  disease,  in  some  cases  it  assumes  a 
chronic  form,  so  that  matter  slowly  accumulates  within  the  orbit. 
At  length  the  lids  become  swoln  and  red ;  fluctuation  is  felt ;  the 
abscess  bursts,  and  leaves  a  sinus  which  is  apt  for  a  length  of  time  , 
to  discharge  matter,  even  when  there  is  no  affection  of  the  bones. 

It  sometimes  happens,  in  consequence  of  this  disease,  that  the 
eyeball  remains  permanently  protruded  and  motionless,  from  the 
indurated  and  adherent  state  of  the  cellular  membrane.  In  this 
case,  the  tears  run  over  the  cheek,  the  eyelids  cannot  close,  the  sur- 
face of  the  eye  becomes  inflamed  and  tender,  and  sometimes  head- 
achs  supervene,  with  iusomnolency,  fever,  and  great  anxiety. t 

Causes.  These  are  confessed  to  be,  in  many  cases,  very  ob- 
scure.    Benedict  tells  us  that  this  disease  occurs  for  the  most  part  in 

*  See  pp.  29,  30. 

t  Guthrie  on  the  Operative  Surgery  of  the  Eye,  p.  1 55.     London,  1822. 


215 

plethoric  individuals,  after  sudden  changes  of  temperature,  and  in 
scrofulous  or  otherwise  disordered  constitutions.  Foreign  bodies, 
hrust  with  violence  between  the  edge  of  the  orbit  and  the  eyeball, 
ind  even  slight  injuries,  occurring  in  pecuhar  constitutions,  or  under 
particular  circumstances  of  the  system,  may  bring  on  inflammation 
jf  the  orbital  cellular  membrane.  Thus,  Weller  instances  a  case 
«rhich  occurred  in  a  healthy  young  woman,  who  happened,  while 
n  the  state  of  menstruation,  to  receive  a  slight  lacerated  wound  of 
;he  orbit.  The  fright  occasioned  by  the  injury  brought  on  inter- 
•uption  of  the  menses,  and  without  any  other  apparent  cause,  a 
levere  inflammation  followed  of  the  whole  cavity  of  the  orbit.  The 
jxtirpation  of  orbital  tumours  sometimes  gives  rise  to  severe  inflam- 
mation, ending  in  suppuration. 

TreatTnent.  A  vigorous  antiphlogistic  treatment  must  be  had 
•ecourse  to,  in  the  first  instance.  Copious  and  repeated  bleedings 
Tom  the  arm,  a  liberal  application  of  leeches  round  the  orbit,  cold 
otions  to  the  head,  free  purging,  abstinence,  rest,  and  darkness,  are 
ividently  indicated.  Even  when  the  constitution  is  not  robust,  this 
sort  of  treatment  must  be  followed,  if  we  mean  effectually  to  save 
,he  vision,  and,  it  may  be,  even  the  life  of  the  patient.  The  debil- 
ity arising  from  the  use  of  active  antiphlogistic  means  of  cure  may 
iasily  be  removed,  while  a  temporizing  or  timid  plan  of  treatment 
nay  be  productive  of  the  most  serious  mischief.  If  the  conjunctiva 
s  chemosed,  it  should  be  freely  scarified,  or  pieces  of  it  cut  out, 
^Miich  will  procure  a  considerable  flow  of  blood.  Benedict  recom- 
mends sinapisms  to  tjie  neck,  friction  of  the  forehead  and  temple 
Arith  mercurial  ointment,  and  large  doses  of  calomel  internally. 

An  opening  through  the  conjunctiva,  or  through  the  eyelid,  for 
.he  evacuation  of  the  matter  collected  within  the  orbit,  is  the  chief 
loint  of  the  treatment  in  the  second  stage.  A  deep  and  free  inci- 
sion is  to  be  made  wherever  the  fluctuation  is  discovered  ;  and  even 
ivhen  there  is  no  distinct  fluctuation,  if  other  symptoms  are  present 
ivhich  lead  us  to  conclude  that  in  all  probability  matter  has  formed, 
I  is  safer  to  plunge  the  lancet  into  the  part  which  is  swollen,  and 
vvhere  we  think  suppuration  is  most  hkely  to  have  taken  place,  than 
,0  allow  the  matter  to  accumulate,  the  bones  perhaps  to  suffer,  or 
3ven  the  brain  to  become  affected. 

Of  course,  in  opening  the  abscess,  care  must  be  taken  to  avoid 
the  eyeball  and  other  important  parts.  This  incision  ought  to  be 
kept  open  with  a  dossil  of  lint,  and  a  poultice  is  afterwards  to  be 
applied.  The  eye  is  frequently  to  be  fomented  with  decoction  of 
poppies,  or  aqueous  solution  of  opium.  At  the  second  or  third 
dressing,  after  the  abscess  has  been  evacuated,  the  opening  into 
the  orbit  may  be  cautiously  examined  with  the  probe.  If  it  is  not 
deep,  the  dossil  of  lint  is  gradually  to  be  diminished  in  thickness, 
and  pushed  less  into  the  orbit,  till  the  sinus  closes  completely.  If, 
)on  the  other  hand,  the  sinus,  or  sinuses  are  deep,  running  back 
lalmost  to  the  bottom  of  the  orbit,  a  mixture  of  tepid  water  and 


216 

laudanum  ought  daily  to  be  injected.  This  is  to  be  continued  till 
the  probe  is  found  not  to  pass  beyond  the  eyeball.  The  lint  may 
be  introduced  to  this  depth,  and  is  not  to  be  lessened  till  the  back 
part  of  the  sinus  close.  1  have  already  explained  the  necessary 
treatment  in  cases  where  the  bones  of  the  orbit  are  found  to  be 
affected.* 

If  the  eyeball  has  suffered  much,  so  that  the  aqueous  chambers 
are  distended  with  pus,  it  will  be  proper  to  open  the  cornea ;  but 
if  only  a  small  quantity  of  matter  is  lodged  in  the  anterior  chamber, 
or  between  the  lamellae  of  the  cornea,  we  may  rely  on  this  being 
absorbed,  if  the  general  inflammation  of  the  eye  and  orbit  is  once 
subdued.  To  promote  the  absorption  of  matter,  it  is  recommended 
to  touch  the  cornea  once  a  day  with  the  vinous  tincture  of  opium. 

In  four  or  five  days  after  the  orbital  abscess  is  opened,  all  the 
dangerous  symptoms  have  in  general  subsided,  and  the  use  of  active 
antiphlogistic  remedies  may  be  laid  aside.  Easily  digested  food, 
in  moderate  quantities,  may  be  allowed,  and  if  the  patient  has  been 
much  weakened  by  the  previous  depletion,  some  such  tonic  may 
be  given  as  is  not  apt  to  excite  the  vascular  system. 

Cases.  I  have  already  stated  the  principal  circumstances  of  a 
case  related  by  Saint- Yves,  and  of  another  by  Demours,  in  which 
this  disease  ended  in  extensive  caries  of  the  orbit.t 

Mr.  Lawrence  has  related,  with  his  usual  clearness,  two  cases 
which  fell  under  his  care  in  an  early  stage  of  the  complaint. 
"  Some  time  ago,"  says  he,  "  I  saw  two  instances  of  this  affection, 
in  which  the  local  and  general  symptoms  were  characterized  by  a 
degree  of  violence  which  I  have  hardly  ever  witnessed  in  any  other 
case.  One  was  that  of  a  young  man  between  twenty  and  thirty 
years  of  age ;  he  came  to  me  accompanied  by  his  wife,  who  told 
me  that  he  had  suffered  such  agonizing  pain  for  the  three  or  four 
preceding  nights,  that  she  was  afraid  he  would  have  gone  out  of 
his  mind.  In  this  case,  matter  was  presenting  just  under  the  su- 
perciliary ridge :  after  making  a  free  opening,  a  large  quantity 
issued  out,  and,  upon  putting  in  a  probe,  it  went  to  the  bottom  of 
the  orbit.  The  other  case  occurred  in  a  child  between  three  and 
four  years  old ;  the  local  and  general  symptoms  were  equally 
severe ;  the  matter  presented  between  the  lower  lid  and  the  globe, 
but  the  quantity  discharged,  on  making  an  opening,  was  not  very 
considerable  in  this  case.  In  both  instances  the  globe  of  the  eye 
was  very  much  protruded,  but  not  actually  thrust  out;  and  after 
the  matter  was  discharged  it  receded  to  its  natural  situation ;  in 
the  child,  vision  was  restored,  but  in  the  adult  the  eye,  although  it 
had  not  been  inflamed,  remained  amaurotic."  X 

A  case  is  recorded  by  Mr.  Guthrie,  of  a  soldier,  wounded  by  a 
bayonet,  wliich  penetrated  into  the  orbit  without  injuring  the  eye,  , 
The  symptoms  which  ensued  were  trifling,  until  the  patient  con-  ' 

*  See  Chapter  I.  Section  ii.  t  See  p.  30. 

t  Lectures  in  the  Lancet,  Vol.  ix.  p.  500.    Lon^ion,  1826. 


217 

irived,  three  days  afterwards,  to  absent  himself  for  twenty-four 
hours,  and  get  drunk.  On  his  return,  the  eyeball  was  protruded, 
;he  lid  could  not  be  raised  so  as  to  expose  the  eye,  which  was 
bighly  inflamed  ;  chemosis  had  taken  place,  vision  was  indistinct, 
;he  iris  was  discoloured,  the  pupil  contracted  ;  the  pain  was  excru- 
Mating,  both  in  the  eye,  which  felt  as  if  it  were  too  large  for  the 
Drbit,  and  all  over  the  forehead  and  temple  of  that  side ;  flashes  of 
light  of  various  colours  darted  through  the  eye,  in  consequence  of 
:he  surrounding  pressure  upon  it;  the  swelling  increased,  the 
patient  became  delirious,  and  an  abscess  burst  in  the  upper  eyelid 
on  the  fourth  day,  without  any  alleviation  of  the  symptoms.  He 
soon  afterwards  became  comatose,  and  died,  probably  from  the 
formation  of  matter  within  the  cranium.  The  eye  had  previously 
been  lost  by  the  sloughing  of  the  cornea.* 

Dr.  Abercrombie  quotes,  from  Burseiius,  what  appears  to  have 
been  an  instance  of  inflammation  of  the  orbital  cellular  membrane, 
terminating  fatally  by  suppuration  extending  within  the  cranium. 
A  woman,  after  suffering  for  a  fortnight  severe  pain  in  the  left  side 
of  the  head,  was  seized  with  swelling  and  inflammation  on  the 
left  eyebrow,  eyelids,  and  cheek.  After  several  days,  the  swelling 
suppurated  and  discharged  much  matter,  and  the  left  eye  was 
found  to  be  blind ;  after  a  few  days  more,  she  was  seized  with 
convulsions,  and  died  comatose.  On  dissection,  the  external  sup- 
puration was  found  to  have  penetrated  to  the  bottom  of  the  orbit, 
betwixt  the  bone  and  the  ball  of  the  eye,  without  injury  of  the  ball 
itself;  internally  there  was  an  extensive  collection  of  matter,  which 
communicated  freely  with  the  cavity  of  the  orbit.t 


SECTION  II. INFILTRATION  OF  THE  ORBITAL  CELLULAR  MEM- 
BRANE. 

There  are  several  very  remarkable  instances  recorded  of  exoph- 
thalmos, in  which  there  appears  to  have  existed  neither  inflamma- 
tion of  the  orbital  cellular  membrane,  nor  any  circumscribed  orbi- 
tal tumour.  In  some  of  th  ecases  to  which  I  refer,  the  exophthalmos 
yielded  after  the  use  of  internal  remedies,  and  although  it  is  im- 
possible to  determine  the  exact  nature  of  the  cause  to  which  the 
protrusion  of  the  eye  was  owing,  the  facts  are  too  valuable  to  be, 
on  this  account,  passed  over  without  notice.  Saint- Yves  entitles 
the  chapter  in  which  he  gives  the  three  cases  which  I  am  about  to 
quote  from  his  work,  Des  Amas  df Hmneurs  qui  se  font  derriere 
le  Globe  de  V  CEil.  The  case  which  I  have  already  quoted  at 
page  72,  from  Landmann,  proves,  by  dissection,  that  the  eye  may 
be  pushed  from  the  socket,  by  a  cause  quite  distinct  from  abscess 
on  the  one  hand,  and  on  the  other  from  circumscribed  tumour. 

*  Lectures  on  the  Operative  Surgery  of  the  Eye,  p.  146.     London,  1823. 
+  Abercrombie  on  Diseases  of  the  Brain,  p.  43.     Edin.  1828. 

.      28 


218 

Inflammation  of  the  periosteum  of  the  orbit,  terminating  in  thick- 
ening' of  that  rriembrane,  might  give  rise  to  similar  ss'mptoms  as 
those  produced  by  infiltration  of  the  orbital  cellular  membrane,  and 
might  yield,  peihaps.  to  the  same  remedies. 

Case.  1.  In  the  first  case  related  by  Saint- Yves,  he  supposes 
the  fatty  cellular  substance  behind  the  globe  of  the  eye.  as  well 
as  the  lachrymal  gland,  to  have  been  tumefied  by  the  efTusion  of 
a  viscid  fluid.  The  eyeball  was  protruded  at  least  three  lines. 
Several  surgeons  who  were  consulted  wished  to  extirpate  the  lach- 
rymal gland,  in  the  hope  that  the  suppuration  of  the  wound  would 
lead  to  the  replacement  of  the  eye,  and  dissipate  the  swelling  within 
the  orbit.  Saint- Yves  objected  to  this  proposal,  being  afraid  lest 
the  disease,  which  appeared  to  him  of  a  scrofulous  nature,  might 
degenerate  into  cancer.  He  cured  it  perfectly  by  a  three  months' 
course  of  cethiops  mineral. 

Case  2.  The  subject  of  Saint- Yves"  second  case  was  a  young 
man,  who  came  to  Paris,  with  the  globe  of  the  eye  inflamed,  af- 
fected with  epiphora,  and  extremely  protruded.  The  eyelids, 
pressed  by  the  globe  against  the  edge  of  the  orbit,  were  swoln, 
and  the  upper  was  even  beginning  to  be  livid,  as  if  read}^  to  fall 
into  a  state  of  gangrene.  The  patient  attributed  his  complaint  to 
a  coup  de  soleil.  which  had  been  followed  first  of  all  by  pain  deep 
in  the  orbit,  and  then  by  protrusion  of  the  eyeball.  Saint- Yve~: 
concluded  from  the  symptoms;  that  either  there  was  an  abscess 
behind  the  eye,  or  that  the  fatty  cellular  membrane  of  the  orbit 
was  tumefied  by  infiltration.  Had  he  been  certain  that  it  was  ab- 
scess, he  would  have  pushed  a  lancet  through  the  orbicularis  pal- 
pebrarum to  the  bottom  of  the  orbit,  but  afraid  of  doing  so  without 
reason,  he  resolved  to  try  the  eflfect  of  a  sorbefacient  treatment. 
He  ordered,  therefore,  eight  grains  of  calomel  at  night,  with  a 
dose  of  senna,  manna,  and  jalap  next  morning  :  and  in  the  mean- 
time bled  the  patient  from  the  external  jugular  vein.  Finding 
that  the  first  dose  produced  some  good  effect,  he  continued  the 
calomel  and  the  purgative  mixture ;  and  in  a  few  days  had  the 
satisfaction  of  finding  the  exophthalmos  completely  removed. 

Case  3.  Saint- Yves  relates  a  third  case,  in  which  the  symp- 
toms were  for  a  time  alleviated  b}'  the  use  of  remedies  :  but  at 
length  the  pain  gro\\-ing  insupportable,  and  totall}-  preventing 
sleep,  the  eye  at  the  same  time  becoming  disorganized,  he  removed 
the  contents  of  the  orbit.  Unfortunately  he  neglects  to  give  any 
account  of  their  appearance  on  dissection,  although  he  speaks  con- 
fidently of  the  cause  of  the  protrusion,  as  un  amas  d'humeurs 
visqueses* 

Case  4.  Louis  quotes,  from  the  Medicina  t^eptejitrionalis 
of  BonetuS;  the  case  of  a  girl  of  three  years  of  age,  whose  right 
eye  was   almost  entirely  protruded  from  the  orbit.     Bonetus  was 

*  Nouveau  Traite  des  Maladies  des  Yeus.  p.  141.     Paris.  1722. 


219 

isked  whether  a  setoii  in  the  neck  was  hkely  to  be  useful.  He 
observed  that  the  child's  clothes  were  much  shorter  before  than  be- 
iiind,  and  this  led  him  to  examine  the  abdomen.  He  found  it  ex- 
rernely  tumid,  tense,  and  hard.  The  child,  in  fact,  presented  the 
symptoms  of  tabes  infantum,  Bonetus  thought  that  nothing  could 
1 36  done  directly  for  the  eye,  but  that  the  obstructed  state  of  the 
bowels  only  should  be  attended  to.  After  being  purged,  she  was 
3ut  on  the  use  of  tincture  of  rhubarb  for  a  month.  The  exophthal- 
7103  gradually  decreased  as  the  abdomen  fell;  and  by  the  time 
i;hat  the  digestive  organs  were  restored  to  a  state  of  health,  the 
3yeball  had,  without  any  other  means  of  cure,  recovered  complete- 
y  its  natural  situation.* 


(SECTION  III. SCIRRHUS  OP  THE  ORBITAL  CELLULAR  MEM- 
BRANE. 

I  have  repeatedly  seen  the  cellular  substance  near  the  front  of  the 
')rbit  become  hard  and  tuberculated,  in  consequence  of  slow  inflam- 
TQation,  occasioned  by  an  injury.  In  one  instance  a  piece  of  lime- 
stone struck  the  outer  edge  of  the  orbit,  producing  a  lacerated  wound 
^  3f  no  great  extent,  and  which  readily  healed.  Some  time  after  a 
small  hard  swelhng  formed  at  the  site  of  the  injury,  was  extirpated, 
md  was  found  to  contain  a  minute  fragment  of  hmestone.  After 
some  months,  another  small  tumour  made  its  appearance  in  the 
5arae  spot,  and  in  connexion  with  it  another,  attached  so  firmly  to 
-he  edge  of  the  orbit,  that  it  was  taken  for  an  exostosis.  In  a  few 
veeks,  a  third  circumscribed  swelling  was  discovered  running  along 
.he  lower  edge  of  the  orbit,  more  movable  than  that  last  mentioned, 
Dut  firm  to  the  touch  as  a  piece  of  cartilage.  The  patient  was 
ander  the  care  of  Mr.  Samuel  Clarke,  of  this  town,  whom  I  assisted 
it  the  removal  of  the  tumours.  The  two  which  felt  so  like  exos- 
oses,  lay  partly  within  the  orbit,  and  adhered  firmly  to  its  perios- 
teum. On  making  a  section  of  them,  they  presented  the  white 
striated  texture  of  scirrhus.  The  extirpation  was  accomplished 
ifter  a  semilunar  incision,  running  parallel  to  the  outer  and  lower 
3dge  of  the  orbit,  and  every  particle  of  indurated  substance  was 
carefully  removed.  Nearly  a  year  has  elapsed  since  the  operation, 
and  there  has  been  no  return  of  the  disease. 


SECTION  IV STEATOMATOUS   AND  ENCYSTED  TUMOURS  IN 

THE  ORBIT. 

Sytnptoms.  Whatev^er  be  the  nature  of  a  morbid  growth  with- 
in the  orbit,  be  it  steatomatous,  encysted,  aneurismal,  or  osseous, 
it  necessarily  gives  rise  to  displacement,  protrusion,  and  iramobilit)'' 
of  the  eye,  pressure  on  the  eyeball  and  its  nerves  so  as  to  cause 

*  Memoires  de  1' Academic  de  Chirurgie,  Tome  xiii.  p.  35D.  12mo.     Paris,  1774» 


220 

pain,  and  traction  of  the  optic  nerve,  which,  added  to  the  pressure, 

brings  on  amaurosis.  This  last  is  often  the  earhest  symptomwhich 
attracts  attention.  A  great  degree  of  deformity  is  produced  by  the 
unnatural  position  of  the  eyeball  in  such  cases,  even  when  it  is  not 
at  all  affected  in  structure.  There  is  intolerance  of  light,  the  tears 
run  over  the  cheek,  the  pain  extends  from  the  orbit  to  the  head, 
and  at  length  the  eye  inflames,  and  is  disorganized. 

The  steatoraatous  or  sarcomatous  tumours  of  the  orbit  are  more 
or  less  of  a  firm  consistence,  and  often  very  hard.  They  are  more 
rare,  and  grow  more  slowly  than  the  encysted  tumours,  but  seldom 
reach  so  great  a  size.  They  appear  altogether  beyond  the  influence 
of  sorbefacient  remedies,  as  indeed  do  also  the  encysted  tumours ; 
the  latter,  however,  are,  at  least  in  many  cases,  susceptible  of  a 
palliative  cure,  while  for  the  former  there  is  no  resource  but  extir- 
pation. When  an  encysted  tumour  contains  a  fluid,  the  cyst  may 
be  punctured  with  temporary  rehef ;  and  in  some  instances,  this 
has  been  followed  by  a  radical  cure,  although  it  is  undoubtedly  the 
preferable  plan  to  remove  the  tumour  completely.  The  contents 
of  the  encysted  tumours  are  very  various  ;  sometimes  limpid  like 
white  of  egg,  in  other  cases  a  thick  bloody  fluid,  in  others  a  sub- 
stance like  pap  or  honey,  in  some  rare  cases  a  collection  of  the  par- 
asitical zoophites  called  hydatids. 

No  part  of  the  orbit  is  exempt  from  becoming  the  seat  of  steato- 
matous  and  encysted  tumour.  They  grow  near  the  front  of  the 
cavity,  so  as  from  the  first  to  advance  before  the  eyeball.  Their 
most  frequent  situation  is  below  the  eye  and  somewhat  behind  it. 
They  grow  above  and  behind  the  eye.  Less  frequently  are  they 
found  by  the  nasal  or  temporal  side  of  the  orbit.  In  some  cases, 
they  have  surrounded  the  optic  nerve. 

The  connexions  of  these  tumours  are  very  different  in  different 
cases  ;  sometimes  loose,  so  that  on  exposing  the  tumour,  it  is  easily 
separated  and  extracted,  while  in  other  cases  it  adheres  fii'mly  to 
the  muscles  and  nerves,  insinuates  itself  between  these  parts,  in- 
volves the  lachrymal  gland,  or  adheres  firmly  to  the  eyeball,  the 
optic  nerve,  or  the  walls  of  the  orbit. 

They  have  all  a  tendency  to  advance  out  of  the  cavity  of  the 
orbit;  pushing  on  between  its  walls  and  the  eyeball,  pressing  the 
eyeball  forwards  and  to  one  side,  projecting  the  eyelids  or  everting 
them,  and  elevating  the  conjunctiva.  When  considerably  ad- 
vanced, we  are  able  to  detect  a  degree  of  fluctuation  in  many  of  the 
encysted  tumours,  while  the  steatomatous  feel  sohd  and  resisting. 
The  encysted  are  often  so  soft,  that  on  pressure  they  seem  to  retire 
within  the  orbit,  appearing  again  as  soon  as  the  pressure  is  removed. 
They  are  always  more  elastic  to  the  touch  than  the  steatomatous 
tumours. 

It  is  a  fact  worthy  of  remark,  that  the  pressure  of  a  tumour 
within  the  orbit  will  sometimes  dilate  that  cavity,  or  induce  inflam- 
mation and  caries  gf  its  walls,  the  eyeball  continuing  to  resist  the 


221 

effects  of  the  pressure  ;  while  in  other  cases,  the  eyeball  inflames, 
bursts,  and  is  destroyed.  A  tumour  in  the  orbit,  if  altogether  left 
to  itself,  may  extend  to  a  very  great  size,  and  at  length  prove  the 
occasion  of  the  patient's  death  by  pressure  on  the  brain. 

Causes.  Blows  on  the  edge  of  the  orbit,  and  exposure  to  cold, 
-are  the  causes  most  frequently  referred  to  in  the  cases  of  orbital  tu- 
•mours  on  record. 

Treatment.  1.  Extirpation  of  steato?natous  twmours.  This 
may  occasionally  be  eifected  by  dividing  merely  the  skin  or  the 
conjunctiva,  according  to  the  situation  of  the  sweUing,  laying  hold 
of  the  tumour  with  a  hook  or  pair  of  hooked  forceps,  or  passing  a 
ligature  through  it,  dragging  it  forwards,  and  dissecting  it  out  with 
a  small  scalpel.  In  other  cases,  it  is  necessary,  in  order  to  effect 
the  extirpation  of  the  tumour  with  ease,  first  to  disunite  the  eyelids 
by  an  incision,  carried  from  their  outer  angle  towards  the  temple. 
The  conjunctiva  covering  the  tumour  is  thus  completely  exposed, 
and  all  the  remaining  steps  of  the  operation  effected  with  less  diffi- 
culty. When  the  tumour  lies  close  to  the  bones  of  the  orbit,  and 
is  perhaps  adherent  to  its  periosteum,  the  extirpation  is  more  readily 
effected  by  cutting  through  the  eyelid  in  a  direction  parallel  to  the 
fibres  of  the  orbicularis  palpebrarum,  and  along  the  edge  of  the  or- 
bit, leaving  the  conjunctiva  untouched.  A  perpendicular  division 
of  the  lid  covering  the  tumour  has  sometimes  been  had  recourse  to, 
but  ought,  if  possible,  to  be  avoided.  The  tumour  is  to  be  extirpat- 
ed, if  possible,  without  injuring  the  parts  in  its  neighbourhood,  or 
to  which  it  adheres.  They  are  to  be  separated  from  it  by  cautious 
touches  with  the  point  of  the  scalpel,  with  a  silver  knife  which 
serves  to  tear  rather  than  cut,  or  with  the  finger-nail.  But  if  the 
adhesions  be  inseparable,  the  parts  to  which  the  tumour  adheres 
must  be  sacrificed.  Even  the  eyeball  will  sometimes  require  to  be 
removed.  No  portion  of  the  tumour  ought  to  be  left,  else  the  dis- 
ease will  be  apt  to  be  reproduced.  After  the  tumour  is  extirpated, 
the  displaced  eyeball  sometimes  returns  immediately  to  its  natural 
situation,  and  recovers  its  power  of  motion  ;  but  in  general  this  is 
effected  not  at  once,  but  slowly  in  the  course  of  several  weeks  or 
even  months,  and  may  sometimes  be  assisted  by  the  application  of 
a  compress  and  bandage.  The  removal  of  the  pressure  caused  by 
the  tumour  is  in  some  cases  followed,  more  or  less  immediately,  by 
restoration  of  the  sight  of  the  eye  ;  while  on  the  other  hand,  I  have 
known  the  sweUing  and  inflammation  subsequent  to  extirpation  of 
an  orbital  tumour,  produce  for  a  time  a  greater  degree  of  displace- 
ment than  had  previously  existed,  and  a  total  loss  of  vision,  in  an 
eye  with  which,  although  much  displaced,  the  patient  had  contin- 
ued to  see  till  the  operation.  The  severe  inflammation  which 
sometimes  follows  the  extirpation  of  an  orbital  tumour,  may  even 
extend  to  the  brain  or  its  membranes,  and  prove  fatal. 

Cases.  Of  the  numerous  cases  of  steatoraatous  orbital  tumours 
on  record,  I  shall  select  a  few,  so  as  to  illustrate  the  most  remarka- 
ble circumstances  attending  this  kind  of  disease,  and  its  treatment. 


222       ^ 

-  Case  1.  Tumour  extirpated  through  the  conjunctiva,  after 
disunion  of  the  eyelids.  A  woman  of  about  40  years  of  age  wap 
admitted  a  patient  at  tlie  Surgical  Hospital  of  Gottingen,  under  the 
care  of  Professor  Langenbeck.  Her  left  eye  was  very  prominent; 
and  at  the  same  time  pressed  upwards  and  inwards.  The  lower 
fold  of  the  conjunctiva  was  protruded  by  a  hard  swelling,  which 
pressed  down  the  lower  eyelid,  and  surrounded  the  eyeball  from  the 
inner  canthus  to  the  outer,  and  hence  to  the  upper  edge  of  the  orbit. 
This  swelling  was  somewhat  movable,  and  could  be  surrounded 
by  the  fingers,  so  that  no  firm  adhesions  were  to  be  expected.  The 
protruded  eye  was  of  natural  appearance,  the  pupil  was  regular, 
and  the  iris  expanded  and  contracted,  but  there  was  no  Arision. 
This  Langenbeck  explains  by  supposing  that  the  organs  which 
produce  and  transmit  the  sensations  of  light  were  deprived  of  their 
activity  by  the  pressure  on  the  eye,  and  the  elongation  of  the  optic 
nerve ;  while,  on  the  other  hand,  the  protrusion  of  the  e5'eball  did 
not  operate  so  injuriously  on  the  cihary  nerves,  which,  from  their 
flexuous  course,  could  sustain  a  considerable  degree  of  traction 
without  their  functions  being  impeded.  Langenbeck  began  the 
operation  by  dividing  the  outer  commissure  of  the  eyelids  and  the 
conjunctiva.  After  both  eyelids  were  separated  from  the  swelling, 
it  was  seen  to  be  a  steatomatous  tumour,  connected  with  the  eye- 
ball and  its  muscles.  The  separation  from  these  parts  was  accom- 
plished partly  with  the  cutting  part  of  the  scalpel,  partly  with  its 
handle,  and  partly  with  the  finger.  The  large  opening  left  after 
the  extirpation  of  the  tumour  was  filled  with  charpie,  till  granula- 
tions appeared.  The  eyeball  gradually  retired  within  the  orbit,  and 
the  power  of  vision  returned  so  completel}^  that  the  patient  could 
distinguish  the  smallest  object  before  she  left  the  hospital.  The 
deformit}'  also  was  entirely  removed.* 

Case  2.  Tumour  extirpated  through  an  incision  of  the  lower 
eyelid — Eyeball  restored  to  its  place  by  pressure.  One  of  the 
most  interesting  cases  of  steatomatous  orbital  tumour  is  related  by 
Dr.  Thomas  Hope.  The  patient  was  a  girl,  eighteen  years  of 
age,  who,  when  about  eleven,  began  to  have  her  left  eye  turned 
towards  the  temple,  by  a  tumour  betwixt  the  globe  and  the  orbit. 
This  tumour,  for  some  years,  did  not  appear  outwardly :  but,  in- 
creasing by  degrees,  at  last  a  hard  swelling  was  perceived  exter- 
nally, reaching  from  the  inner  almost  to  the  outer  angle,  under  the 
lower  eyehd,  and  half  an  inch  down  on  the  cheek.  It  forced  the 
globe  of  the  e3^e  almost  out  of  the  socket,  so  that  the  pupil  of  that 
eye  was,  by  measure,  above  3-4ths  of  an  inch  farther  from  the  nose 
than  the  pupil  of  the  other,  while  the  eyeball  was  so  prominent, 
that  it  seemed  to  be  out  upon  ihe  temple.  It  was  quite  immovable, 
but  the  sight,  although  a  good  deal  impaired,  was  not  lost.  The 
patient  had  frequent  pains  in  her  head.     Dr.  Hope,  having  resolved 

t  rseue  Bibliothek fUr  die  Chirurgie  und  Ophtlialmologie.     Vol.  ii.  p.  238.     Hano- 
ver, 1819. 


223 

to  extirpate  the  tumour,  made  an  incision  about  an  inch  long,  be- 
ginning at  the  inner  angle,  and  following  the  direction  of  the  fibres 
of  the  orbicular  muscle,  towards  the  outer  angle.  He  then  passed 
a  crooked  needle,  armed  with  silk,  through  the  middle  of  the 
tumour  as  deep  as  he  could  go.  By  this  means  raising  the  tumour, 
he  separated  with  a  bistoury,  all  its  lateral  adhesions,  with  the 
scissois  cut  the  deeper  attachments  which  he  could  not  so  well  reach 
with  the  bistoury,  and  brought  away  all  that  the  thread  had  hold 
of.  This  seemed  to  be  a  tough  membranous  substance,  indepen- 
dent of  the  real  tumour,  which,  after  it  was  quite  taken  out,  was 
found  to  be  of  a  spherical  figure,  smooth,  and  even,  about  the  big- 
ness of  a  small  pigeon's-egg.  Dr.  H.  passed  the  needle  through 
the  middle  of  it,  as  he  had  done  before,  and  plunged  a  lancet  into 
it  as  deep  as  he  could,  in  order  to  let  out  any  fluid  matter  that  it 
might  contain,  but  found  nothing  but  a  carnous  substance.  Lift- 
ing up  the  tumour  by  the  thread,  he  cautiously  dissected  it,  as  far 
as  he  could,  from  the  adjacent  parts.  In  doing  this,  he  found  on 
the  side  next  the  eye  several  strong  callous  attachments,  which  felt 
almost  as  hard  as  cartilage,  and  obhged  him  to  change  two  or  three 
instruments.  He  then  with  the  scissors,  cut  the  inward  adhesions 
at  the  roots,  and  brought  the  tumour  away  entire.  On  putting  in 
his  finger  to  the  bottom  of  the  orbit,  he  could  feel  several  hard  cal- 
lous substances  still  remaining.  Keeping  his  finger  upon  them,  he 
hooked  them  with  a  crooked  needle  and  ligature,  and,  making  an 
assistant  raise  the  thread,  with  the  scissors,  he  cut  them  away,  so 
that  he  left  the  bottom  even,  and  entirely  free,  as  far  as  he  could 
judge.  All  this  while  there  was  no  great  effusion  from  any  artery, 
but  a  good  deal  of  black  grurnous  blood  from  the  varicose  vessels. 
He  dressed  the  wound  with  dry  lint,  which  he  removed  on  the  third 
day,  when  he  found  a  soft  swelling  in  the  eyelids  and  conjunctiva, 
wnth  shght  inflammation,  and  pain  in  the  forehead.  He  applied  a 
soft  dossil  dipt  in  common  digestive  and  warm  brandy,  and  ordered 
a  warm  fomentation  every  two  hours.  The  pain  in  the  forehead, 
and  the  swelling,  continued  for  three  or  four  days,  without  any  ap- 
pearance of  matter.  He  then  touched  the  bottom  of  the  wound 
with  lunar  caustic.  Some  hours  after,  there  followed  a  pretty  large 
discharge  of  blackish  blood,  and  immediately  the  head  was  relieved 
and  the  swelling  subsided.  A  bloody  sanies  continued  to  issue  out 
the  two  following  days,  for  which  he  injected  warm  water,  with  a 
little  brandy  and  honey  of  roses,  after  which  the  wound  began  to 
heal  up.  The  eye  still  continued  immovable.  The  abductor 
muscle  had  been  so  long  contracted  and  the  adductor  overstretched, 
that  they  had  lost  their  use.  Dr.  H.  observed,  however,  that  by 
pressing  gently  with  his  hand  upon  the  globe  of  the  eye,  he  could 
bring  it  a  good  deal  more  into  the  socket,  and  that  upon  taking 
away  his  hand  it  returned  to  its  former  place.  This  made  him 
think  that  a  constant  and  gradual  pressure,  by  some  proper  band- 
I  age,  might  be  of  service  to  force  the  eye  into  its  place,  and  keep  it 


224 

there  till  the  muscles  should  recover  their  tone.  Accordingly,  he 
procured  a  steel  bandage,  with  a  concave  brass  plate  corresponding 
to  the  convexity  of  the  eye,  and  which,  by  means  of  a  screw,  bore 
upon  the  side  of  the  eye  next  the  temple.  He  applied  this  bandage, 
first  gently  forcing  the  eye  more  into  its  place  with  his  hand,  and 
then  putting  a  thick  soft  compress  betwixt  the  eye  and  the  brass 
plate.  He  then  screwed  it  down  in  such  a  manner  that  it  was 
impossible  for  the  eye  to  start  back  again  as  it  used  to  do.  An 
assistant  was  left  with  the  patient  all  night  with  instructions,  if  the 
bandage  caused  great  pain,  to  ease  the  screw. 

By  keeping  the  bandage  constantly  applied,  day  and  night, 
and  gradually  increasing  the  pressure,  in  about  twenty  days  the 
eye  was  brought  entirely  into  its  place,  so  as  to  remain  there 
of  itself,  performing  all  its  natural  movements,  and  the  patient 
seeing  with  that  eye  as  well  as  with  the  other.  In  the  morning, 
when  the  bandage  was  taken  off,  Dr.  H,  could  observe  that  side 
of  the  eye  which  the  plate  bore  upon  considerably  flattened ;  yet 
this  was  not  attended  with  any  pain,  or  bad  consequence.  In  about 
a  month,  the  wound  was  quite  healed  up.  A  spongy  carnosity 
had  grown  all  along  the  inside  of  the  lower  eyelid,  which,  having 
been  long  over-stretched  by  the  tumour,  was  so  relaxed,  that,  after 
the  operation,  it  turned  inside  out ;  while  the  upper  eyelid,  having 
been  very  much  extended  for  so  many  years  by  the  globe,  upon 
the  eye  returning  to  its  place,  was  so  relaxed,  that  its  cartilage,  on 
the  contrary,  turned  inwards.  For  the  cure  of  the  ectropium  of 
the  lower  lid,  Dr.  H.  passed  a  crooked  needle  through  the  middle 
of  the  carnosity,  and  raising  it  by  the  thread,  cut  it  off  with  the 
scissors.  He  afterwards  touched  the  inside  of  the  lid  with  lunar 
caustic,  in  order  to  destroy  what  remained  of  the  carnosity,  and 
giving  the  eschar  time  to  be  thrown  off,  he  repeated  the  same  twice 
or  thrice,  by  which  the  lid,  in  about  a  fortnight,  recovered  its  proper 
situation.  By  topical  applications,  the  upper  eyelid  recovered  its 
strength,  so  that  he  did  not  find  it  necessary  to  operate  for  the  en- 
tropium.  Dr.  H.  concludes  his  account  of  the  case,  by  expressing 
his  surprise  how,  after  so  great  a  degree  of  elongation  of  the  optic 
nerve,  for  seven  years,  the  patient's  vision  should,  in  a  month's 
time,  be  so  perfectly  restored,  and  the  muscles,  after  so  long  disuse^.- 
recover  so  soon  their  natural  action.*  ' 

Case  3.  Tumour  extirpated  through  a  perpendicular  in- 
cision of  the  upper  eyelid — Disease  returns.  Dr.  Monteath 
shortly  states  the  case  of  a  young  girl,  who  had  a  tumour  on  the  \ 
upper  and  outer  side  of  the  orbit.  In  order  to  get  at  it,  he  was^ 
obliged  to  cut  through  the  whole  perpendicular  length  of  the  upper 
eyelid,  and  dissect  back  the  two  flaps.  The  tumour  was  nearly 
the  size  of  a  plum,  and  reached  as  far  back  as  the  eyeball.  It  was 
slightly  encysted,   perfecdy  organized,  and  of  anomalous  texture^ 

*  Philosophical  Transactions  for  1744  and  1745,  Vol.  xliii.  p.  194.    London,  174& 


225 

The  healing  of  the  wound  was  rapici,  and  contrary  to  expectation, 
the  eyelid  re-united  perfectly,  and  regained  very  nearly  its  natural 
power  and  extent  of  motion.  The  eyeball  did  so  also,  and  the 
vision  was  perfect.  The  patient  went  to  England  some  months 
after,  and  Dr.  M.  was  concerned  to  learn  that  the  tumour  had  be- 
gun to  grow  again.* 

Case  4.  Tumour  returns  from  not  being  completely  extir- 
pated—  Operation  rendered  difficult  hy  patient's  resistance. 
Mr.  Wardrop  relates,  that  a  young  woman,  of  a  robust  form,  had 
a  tumour  on  the  orbitar  plate  of  the  left  frontal  bone,  the  base  of 
which  adhered  firmly  to  the  bone,  whilst  the  exterior  portion  was 
attached  to  the  integuments,  in  which  there  was  a  small  sinus 
leading  into  the  interior  of  the  tumour.  The  diseased  mass  did 
not  exceed  the  bulk  of  an  almond,  but  it  was  attended  with  great 
pain,  and  even  cautiously  touching  the  orifice  of  the  sinus  with  a 
probe  excited  violent  irritation.  A  tumour  had  been  extirpated 
from  the  seat  of  this  swelling  some  months  previously,  a  portion 
of  which  adhering  to  the  bone  being  left  behind,  gave  origin  to 
this  new  growth.  Though  she  had  come  from  a  distance,  deter- 
mined to  get  the  disease  removed  by  an  operation,  if  it  was  con- 
sidered advisable,  yet  when  the  scalpel  touched  the  integuments, 
she  made  a  violent  resistance.  A  second  attempt  was  made,  she 
being  previously  secured  on  a  table  with  numerous  assistants  ;  but 
such  was  the  force  and  exertion  she  made  to  extricate  herself 
whenever  the  operation  was  about  to  be  begun,  that  every  hope  of 
success  was  abandoned.  It  now  occurred  to  Mr,  W.  as  the  only 
resource,  that  if  she  would  allow  herself  to  be  bled  to  a  state  of 
deliquium,  the  tumour  might  be  extirpated  while  she  remained 
insensible.  After  a  few  days,  she  submitted  to  this  measure.  A 
large  vein  was  freely  opened  while  she  sat  in  the  erect  posture,  in 
a  very  warm  room,  in  which  there  were  seven  people,  with  the 
doors  and  windows  kept  shut  to  hasten  her  fainting.  No  less  than 
fifty  ounces  of  blood  were  drawn  before  she  fainted,  and  then  a 
complete  state  of  syncope  came  on,  which  lasted  a  sufficient  time  to 
illow  the  tumour  to  be  removed.  The  operation  was  accomplished 
with  great  facihty ;  and  in  order  to  promote  an  exfoliation  of  the 
diseased  portion  of  bone,  its  surface  was  rubbed  over  with  kali 
purum.  When  the  fainting  went  off,  she  would  not  believe  that 
.he  operation  had  been  performed,  until  she  had  examined  her  face 
In  a  glass.  She  suffered  little  from  the  eflfects  of  the  operation ; 
ind  though  she  remained  pale  and  feeble  for  a  few  days  from  the 
profuse  bleeding,  yet  in  a  week  she  was  better  than  most  patients 
ire  who  have  undergone  so  severe  an  operation.f 

Case  5.  Tumour  encircling  optic  nerve — Eyeball  extirpated. 
\.  young  adult  woman  consulted  Dr.  Monteath  on  account  of  an 

*  Translation  of  Weller's  Manuel,  Vol.  i.  p.  195.     Glasgow,  1821. 
t  Medico-Chirurgical  Transactions,  Vol.  x.  p.  275.    London,  1819. 

29 


I 


226 

orbital  disease  of  two  years'  standing,  which  had  produced  hideous 
exopiithalmos.     It  was  found  impracticable  to  extirpate  the  tumour  1 
without  also  removing  the  eyeball,  which  was  accordingly  done.] 
The  tumour  exceeded  the  size  of  the  eyeball,  lay  directly  behind  it,! 
and  so  completely  encircled  the  optic  nerve,  that  the  latter  was  di- 
minished one  half  in  thickness  by  the  pressure.     Vision  had  been 
rapidly  declining  previous  to  the  operation.     The  tumour  was  ex- 
ceedingly hard,  of  anomalous  texture,  and  surrounded  by  a  layer 
of  condensf^d  cellular  substance.     The  anterior  surface  of  the  tu- 
mour touched  and  pressed  upon  the  posterior  surface  of  the  eyeball, 
but  had  no  connexion  with  it  except  through  the  medium  of  the 
optic  nerve  and  cellular  substance.     Twenty  months  after  the  ope- 
ration, the  patient  continued  well.* 

Case  6.  Inflammatioii  of  the  bi'ain  after  extiipation  of  an 
orbital  tumour — Death  within  twenty  four  hours.  Langenbeck 
remarks,  that  on  account  of  the  neighbourhood  of  the  brain,  and 
the  connexion  which  the  parts  contained  within  the  orbit  have  with 
the  membranes  of  the  brain,  the  extirpation  of  orbital  tumours 
is  by  no  means  free  from  danger.  He  instances  the  case  of  a  ro- 
bust man  of  40  years  of  age,  from  whose  orbit  he  extirpated  with- 
out difficulty  a  steatomatous  tumour,  which  had  to  a  considerable 
degree  protruded  the  eye.  After  the  operation,  he  was  enabled  to 
press  the  eye  back  into  its  natural  situation,  so  that  the  deformity 
was  completely  removed.  The  patient  felt  so  well  after  the  opera- 
tion, that  the  most  favourable  termination  of  the  case  was  antici- 
pated. When  Langenbeck  visited  him  two  hours  after  the  opera- 
tion, he  was  asleep.  He  did  not  disturb  him,  but  returning  some 
hours  after,  he  found  him  still  sleeping.  On  observing  him,  he 
saw  that  he  lay  with  his  mouth  open,  and  his  face  affected  with 
convulsive  twitchings.  He  had  torn  off  the  bandage,  and  had  been 
very  restless.  The  sound  eye  was  half  shut.  When  spoken  to, 
he  returned  no  answer.  On  raising  him  up,  he  was  unable  to 
keep  himself  in  that  posture.  The  bandage  was  replaced.  The 
patient  fell  again  into  the  soporose  state,  tossing,  however,  continu- 
ally about,  as  those  are  seen  to  do  who  labour  under  inflammation 
of  the  brain.  He  was  copiously  bled,  cold  applications  were  made 
to  his  head,  and  he  was  freely  purged  with  calomel.  He  became 
quite  insensible,  and  discharged  his  faeces  and  urine  involuntarily. 
In  the  evening,  he  attempted  to  spring  out  of  bed,  and  was  so  un- 
ruly, that  it  was  necessary  again  to  let  blood  from  him.  Gradually 
he  became  quieter,  continued  soporose,  and  died  next  morning. 
Struck  by  the  suddenness  of  this  event,  Langenbeck  inquired  mi- 
nutely into  his  previous  history.  He  learned  that  he  was  habitual- 
ly a  hard  drinker,  especially  of  rum,  and  that  the  evening  before 
the  operation  he  had  come  to  the  hospital  in  a  state  of  intoxication, 
which  had  been  carefully  concealed.  On  dissection,  nothing  un- 
natural was  observed  in  the  orbit,  nor  were  any  remahis  of  the  tu- 

»  Translation  of  "Weller's  Manuel,  Vol.  i.  p.  196.    Glasgow,  1821. 


227 

mour  detected.  On  opening-  the  head,  no  morbid  change  was  re- 
marked on  the  superior  surface  of  the  brain,  but  where  the  inferior 
surface  of  its  anterior  lobe  rested  on  tlie  orbitary  plate  of  the  frontal 
bone,  exactly  above  the  place  of  the  tumour  which  had  been  remov- 
ed, there  was  discoloration,  purulent  exudation,  and  all  the  marks 
of  inflammation.  The  tumour  had  had  no  communication  with 
the  cavity  of  the  cranium.* 

Case  7.  Death  from  erysipelas,  after  extirpation  of  an  or- 
bital tumour.  Dr.  Ballingall,  in  a  clinical  lecture  delivered  to  the 
students  of  the  Royal  Infirmary  of  Edinburgh,  in  March  1828,  and 
afterwards  printed  for  their  use,  states  that  on  the  12th  of  Novem- 
ber 1827,  James  M'Intosh  was  admitted  with  a  soft  movable  tu- 
mour impacted  between  the  roof  of  the  orbit  and  globe  of  the  right 
eye.  The  superior  eyelid  was  protruded  outwards  and  considerably 
inflamed,  as  well  as  the  conjunctiva  covering  the  surface  of  the 
tumour ;  the  ball  of  the  eye  was  depressed  by  the  swelling  towards 
the  cheek.  The  structure  of  the  eye  appeared  perfectly  sound,  and 
the  vision  unimpaired,  except  in  so  far  as  it  was  partially  obstructed 
by  the  projection  of  the  tumour,  which  obliged  the  patient  to  throw 
back  his  head,  and  to  elevate  his  iixce  in  attempting  to  see  objects 
placed  before  him.  He  was  unconscious  of  any  accident  to  which 
this  complaint  could  be  attributed,  assigning  its  origin  to  exposure 
to  cold  in  the  month  of  January  preceding.  In  July,  he  had  been 
in  the  Infirmary,  at  which  time  the  tumour  was  not  above  a  fourth 
of  the  size  it  had  attained  in  November.  In  July,  it  occupied  the 
site  of  the  lachrymal  gland.  He  was  urged  to  have  it  removed,  but 
would  not  consent,  although  told  that  he  would  in  all  probability 
return  with  it  at  a  future  period,  when  the  operation  would  be  more 
difl5cult.  This  accordingly  happened ;  and  in  November  he  was 
solicitous  for  its  removal.  Dr.  B.  began  by  dividing  the  superior 
palpebra  upwards  and  outwards  from  the  external  canthus  of  the 
eye.  After  dissecting  the  eyehd  off  from  the  surface  of  the  sweUing, 
the  tumour  was  with  much  difficulty  separated  from  the  contiguous 
parts ;  a  pedicle  or  neck,  by  which  it  was  found  adherent  to  the 
very  bottom  of  the  orbil,  was  then  cut  across  with  a  pair  of  probe- 
pointed  scissors,  and  some  small  portions  of  it  afterwards  removed. 

The  operation  was  followed,  in  the  first  instance,  by  a  very  mod- 
erate degree  of  swelling  and  inflammation,  much  less,  indeed,  than 
was  to  be  anticipated.  For  nearly  a  week  the  case  had  a  very 
favourable  aspect,  but  at  the  end  of  this  time,  the  forehead  and 
upper  part  of  the  face  became  involved  in  a  violent  erysipelatous 
inflamination,  which  gradually  extended  over  the  whole  head,  ac- 
companied with  dehrium,  his  pulse  rising  as  high  as  150.  It  was 
observed,  soon  after  the  operation,  that  his  breath  was  imbued  with 
the  mercurial  foetor,  which  he  attributed  to  some  medicines  taken 

*  Neue  Bibliothek  far  Chirurgie  und  Ophthalmologic.     Vol.  ii.  p.  241.     Hancver, 


228 

before  his  admission.  The  urgent  symptoms  were  somewhat  alle- 
viated by  bleeding,  both  general  and  topical,  by  the  internal  exhibi- 
tion of  antimonials  and  saline  purgatives,  the  application  of  a  blister 
to  the  nape  of  the  neck,  with  the  use  of  an  anodyne  fomentation 
to  the  inflamed  parts.  On  the  22d,  (Dr.  B.  omits  to  mention  the 
date  of  the  operation),  he  was  found  to  have  sunk  so  low,  that  he 
was  not  expected  to  live  through  the  ensuing  night ;  his  pulse  120, 
his  breathing  laborious,  and  his  extremities  cold,  with  low  mutter- 
ing typhoid  deliiium.  From  this  state  he  again  rallied  under  the 
use  of  brandy  and  water,  beef  tea,  and  the  application  of  a  second 
bUster  to  the  nape  of  the  neck.  A  copious  discharge  of  unhealthy 
matter  had  for  some  days  been  going  on  from  tbe  affected  eye,  the 
cornea  of  which  now  ulcerated,  and  on  the  morning  of  the  27th, 
the  crystalline  lens  was  discharged  through  the  opening.  His  de- 
lirium continued  with  occasional  intermissions,  during  which  he 
asked  for  and  devoured  food  with  a  ravenous  appetite.  His  pulse 
continued  frequent  and  weak,  his  breath  foetid  and  offensive,  and 
his  general  appearance  resembling  that  of  a  patient  in  the  advanced 
stages  of  typhus.  The  cuticle  separated  in  crusts  from  those  parts 
of  the  head  and  face  in  which  the  inflammation  had  been  seated  ; 
rigors  and  diarrhoea  latterly  supervened,  and  he  expired  on  the 
evening  of  the  28th.  Permission  could  not  be  obtained  to  examine 
the  body ;  but  a  hasty  examination  was  made  of  the  head  and 
parts  concerned  in  the  operation.  A  portion  of  the  principal  tumour 
was  found  still  adherent  to  the  sheath  of  the  optic  nerve,  and  seve- 
ral small  melanotic  tubercles  imbedded  in  the  fatty  matter  sur- 
rounding the  muscles  of  the  eye.  Some  serous  effusion  had  taken 
place  both  on  the  surface  and  into  the  ventricles  of  the  brain.  Dr. 
B.  remarks,  that  if  he  had  been  fully  aware  of  the  nature  of  the 
disease,  and  of  the  deep  attachment  of  the  tumour,  he  should  have 
proceeded  at  once  to  extirpate  the  whole  contents  of  the  orbit ;  but 
having  succeeded  in  removing  the  bulk  of  the  tumour  with  safety 
to  the  eyeball,  he  felt  reluctant  to  change  the  plan  of  the  operation. 
The  inflammation  immediately  succeeding  to  the  removal  of  the 
tumour  was  much  less  than  was  to  have  been  expected  from  so 
severe  an  operation,  but  when  the  symptoms  of  erysipelas  super- 
vened, it  was  obvious  that  the  case  became  one  of  a  very  perplexing 
and  hazardous  description.  The  patient's  system  surcharged  with 
mercury  precluded  the  employment  of  mercurial  purgatives,  so  often 
beneficial  in  erysipelatous  inflammation,  and  it  had  been  remarked, 
that  even  when  in  the  hospital  in  Jul}',  he  had  something  of  that 
sallow  cachectic  look  often  attendant  upon  internal  organic  disease, 
and  which  rendered  him,  in  Dr.  B.'s  estimation,  an  unfit  subject 
for  profuse  evacuations  of  blood. 

Case  8.  Orbit  dilated  by  a  steatomatous  tumour — Death 
some  months  after  extirpation.  In  a  lady  of  about  thirty  years 
of  age,  Langenbeck  extirpated  a  tumour  hj  which  the  eye  was 
considerably  protruded  from  the  orbit.     The  temporal  side  of  this 


229 

cavity  was  also  evidently  pushed  outwards.  As  this  deformity  had 
increased  J  the  patient  had  frequently  complained  of  violent  pain  in 
the  head.  The  tumour  was  easily  removed,  the  pain  of  head  sub- 
sided, and  the  wound  healed  readily.  The  eye  retired  in  some 
degreee  into  its  natural  place,  but  the  protuberance  in  the  temple 
remained  unchanged.  After  some  months,  periodic  headachs  came 
on,  and  constantly  increased  till  they  reached  a  high  degree  of  se- 
verity. At  length  she  became  soporose,  and  died.  The  body  was 
not  inspected.* 

2.  Puncture  of  encysted  tumours.  Encysted  tumours,  in  dif- 
ferent parts  of  the  body,  and  especially  in  superficial  situations,  are 
apt  to  burst  in  consequence  of  blows,  or  at  length  give  way  simply 
from  distention,  and  discharge  their  contents.  The  cyst  remains 
for  a  time,  and  seems  to  operate  like  a  foreign  substance ;  inflam- 
mation comes  on,  ending  in  suppuration,  and  either  separately  and 
entire,  or  along  with  the  matter  and  broken  down  into  shreds,  the 
cyst  is  evacuated ;  and  the  cavity,  formerly  occupied  by  the  tumour, 
contracts  and  heals  up.  Upon  this  course,  sometimes  followed  by 
nature,  is  founded  the  practice  of  puncturing  encysted  tumours, 
and  evacuating  their  contents.  It  is  not  a  practice  to  be  much 
commended.  It  is  tedious  and  uncertain  ;  for  the  cyst  may  not 
come  away  for  weeks  or  months,  and  if  any  portion  of  it  is  left 
behind,  or,  as  is  often  the  case,  if  the  whole  of  it  is  left,  a  new  col- 
lection of  fluid  is  apt  to  take  place.  It  may  also  happen  in  the 
orbit,  as  it  has  often  happened  in  other  parts  of  the  body,  that  this 
practice  of  puncturing  encysted  tumours  may  give  rise  to  a  fungous 
growth  from  the  inside  of  the  cyst,  attended  with  great  pain  and 
iiiitation.  The  difficulty,  however,  on  the  one  hand,  of  completely 
extirpating  encysted  tumours  of  the  orbit,  and  on  the  other,  the 
total  subsidence  of  the  swelling,  and  the  return  of  the  eye  to  its 
natural  situation  after  the  contents  of  the  cyst  are  evacuated,  has 
occasionally  led  surgeons  to  content  themselves  with  this  palliative 
plan  of  treatment. 

The  following  is  an  instance  of  the  accidental  bursting  of  an 
orbital  encysted  tumour.  A  lively  girl,  of  about  17  years  of  age, 
had  a  small  opening  at  the  temporal  edge  of  the  left  orbit,  close  to 
the  tarsus  of  the  upper  eyelid.  Every  morning  she  found  the 
neighbourhood  of  this  opening  somewhat  swoln,  and  by  pressure 
evacuated  through  it  a  quantity  of  a  whitish,  pretty  consistent,  ropy 
substance,  something  hke  half-fluid  tallow.  The  origin  of  her 
complaint  was  her  leaping  suddenly  against  a  door,  believing  it  to 
be  open,  when  it  was  shut,  and  which  she  struck  violently  with 
the  left  side  of  her  head.  The  part  immediately  became  swoln 
and  livid.  Fomentations  and  poultices  were  employed,  and  the 
immediate  consequences  of  the  contusion  were  removed.  After 
some  time,  a  small  swelling  made  its  appearance  under  the  skin 

*  Neue  Bibliothek  fUr  Chirurgie  und  Ophthalmologic,  Vol.  ii.  p.  244.    Hanover, 


230 

of  the  part  which  had  been  struck.  This  swelhng  increased,  not- 
withstanding the  use  of  embrocations  and  the  hke,  and  much  dis- 
figured the  ghi's  countenance.  It  had  acquired  the  size  of  a  wal- 
nut, and  a  day  was  fixed  for  its  extirpation,  when  she  happened 
by  accident  again  to  strike  her  head  against  the  same  door  so  vio- 
lently, that  the  cuticle  was  stript  from  off  the  part,  and  the  tumour 
so  much  bruised  that  it  suppurated.  The  alsscess  was  opened,  the 
cyst  gave  way,  and  a  yellowish-white  substance  like  honey,  was 
discharged.  After  which  the  wound  contracted  to  the  small  open- 
ing, which  existed  when  Dr.  Schwarz,  the  narrator  of  the  case, 
saw  the  patient.  He  did  not  think  it  necessary  to  urge  her  to  have 
the  cyst  removed  by  operation,  as  the  inconvenience  of  emptying 
it  from  time  to  time  was  but  trifling.* 

In  the  three  following  cases,  the' puncturing  of  encysted  tumours 
in  the  orbit,  proved  a  radical  cure. 

Case  1.  A  shoemaker,  aged  45  years,  had  the  left  eye  promi- 
nent, and  almost  entirely  ont  of  its  orbit.  This  exophthalmos 
had  come  on  gradually,  attended  with  pain,  but  without  inflam- 
mation. The  eye  was  pushed  out  by  a  hard  tumour,  which  ap- 
peared to  be  situated  between  the  globe  and  the  inner  wall  of  the 
orbit.  Several  practitioners  in  Paris  were  of  opinion  that  the 
tumour  was  cancerous.  The  protruded  eye  was  not  enlarged,  but 
was  deprived  of  sight  from  compression  and  traction  of  the  optic 
nerve.  Richerand  proposed  to  the  patient  to  extirpate  this  sus- 
pected carcinoma,  although  from  the  renitency  of  the  tumour  he 
had  his  doubts  concerning  its  nature.  After  having  disunited  the 
eyelids  at  their  outer  angle,  and  divided  the  conjunctiva,  he  thought 
proper,  before  going  on  with  the  operation,  to  assure  himself  of  the 
real  nature  of  the  disease  by  plunging  into  it  the  point  of  his  knife. 
This  was  followed  by  the  exit  of  two  or  three  ounces  of  a  fluid 
similar  to  white  of  e^g.  Being  now  certain  that  the  exophthalmos 
depended  on  an  encysted  tumour,  and  the  eye  having  already,  in 
consequence  of  the  contraction  of  the  C3'st,  retired  partly  into  its 
natural  place,  Richerand  renounced  the  idea  of  extirpation,  and 
contented  hiujself  witli  applying  wet  compresses  over  the  eye. 
Considerable  inflammation  followed,  for  which  he  bled  the  patient. 
The  cyst  suppurated,  and  the  patient  was  cured  after  the  excision 
of  some  excrescences  formed  by  the  conjunctiva.! 

Case  2.  A  woman  was  brought  to  3Ir.  Weldon,  with  one  of 
her  eyes  considerably  protruded  from  its  usual  situation  in  the  or- 
bit. About  two  years  before,  she  felt  a  fulness  of  the  eye,  and  a 
stiffness  of  the  eyeUds,  so  that  they  moved  with  difficuU)\  As 
these  syrnptoms  increased,  she  became  sensible  of  a  feehng  of  pres- 
sure and  uneasiness  in  ihe  ball  of  the  eye,  which  gradually  became 
painful;  especially  in   moving  it.     At  length  the  eye  became  im- 

*  Grafe  and  Walther's  Journal  der  Chirursie  und  Augen-Heiikonde,  Vol.  vii.  p. 
235.     Berlin,  1825. 
t  Nosographie  Chirurgicale,  Tome  ii.  p.  119.     Paris,  1813.  '  .    ' 


J 


231 

movable,  the  sight  disappeared,  and  the  pain  increased  to  such  a 
degree  of  violence,  that  the  patient  at  times  became  dehrious. 
When  Mr.  W.  saw  her,  the  eye  was  considerably  protruded  for- 
wards, and  rather  upwards,  towards  the  inner  angle,  in  a  manner 
easily  conceived  by  supposing  a  tumour  in  the  orbit  to  press  the 
eye  directly  forward,  while  the  optic  nerve  firmly  resists  the  pressure. 
The  eyelids  were  open  and  immovable,  and  there  was  a  general 
fulness  of  the  surrounding  integuments.  The  sight  had  been  lost 
about  twelve  months.  The  iris  was  motionless,  moderately  di- 
lated, and  had,  (says  Mr.  W.)  a  number  of  fissures  in  it  of  various 
depths,  some  of  which  extended  three-fourths  through  it.  The 
blood-vessels  of  the  eye  were  full  and  turgid,  but  not  inflamed. 
The  pain  she  described  as  being  intolerable,  and  almost  without 
remission,  extending  at  times  over  the  whole  head,  but,  in  general, 
pretty  much  confined  to  the  globe  of  the  eye,  and  the  situation  of 
the  optic  nerve.  It  was  attended  by  a  sense  of  pressure  and  great 
distention.  On  feeling  the  integuments  that  covered  the  orbit  be- 
neath the  eye,  the  sensation  to  the  finger  resembled  that  produced 
by  feeling  a  loose  fatty  substance,  but  on  examining  the  part  more 
attentively,  a  deep-seated  fluctuation  was  very  evident.  The  parts 
were  free  from  any  tenderness  or  pain  on  pressure.  With  a  cata- 
ract-knife, Mr.  W.  made  a  puncture  into  the  tumour,  from  the 
middle  of  the  lower  edge  of  the  orbit,  and  pressed  out  a  small 
quantity  of  transparent  fluid.  He  then  extended  the  wound  for 
near  an  inch  towards  the  outer  canthus,  taking  care  to  keep  the 
point  of  the  knife  sufiiciently  deep,  and  to  carry  it  forwards  at  the 
same  time,  so  as  to  open  the  cyst  very  freely.  About  two  table- 
spoonfuls  of  a  clear  transparent  fluid,  slightly  adhesive,  came  away, 
and  were  followed  by  instantaneous  ease,  while  the  eye  sunk  near- 
ly into  its  natural  situation.  The  lips  of  the  wound  were  kept 
asunder,  and  in  five  or  six  days,  the  cyst,  which  Mr.  W.  fancies 
to  have  been  a  hydatid,  appeared  in  view,  and  was  withdrawn. 
This  coat,  as  Mr.  W.  terms  it,  was  spherical,  rather  thicker  than 
the  coats  of  hydatids  of  a  corresponding  size  usually  are,  and  had 
a  smooth  shining  surface.  The  discharge  gradually  lessened,  and 
the  wound  healed  without  farther  trouble  in  the  course  of  three 
weeks.  The  pain  and  affection  of  the  head  totally  ceased,  and 
the  eye,  to  a  common  observer,  appeared  as  the  other.  The  iris 
remained  motionless,  and  the  sight  was  totally  lost.* 

Case  3.  A  patient  came  under  the  care  of  Mr.  Lawrence, 
complaining  of  considerable  pain  and  distention  in  the  orbit,  with 
dimness  of  sight.  The  globe  of  the  eye  was  a  little  projecting, 
and  on  examination  Mr.  L.  thought  he  could  discover  the  existence 
of  a  tumour  in  the  upper  part  of  the  orbit.  It  was  represented  to 
the  patient  how  the  case  stood,  and  he  was  informed  that  the  only 
effective  mode  of  relief  would  be  the  renaoval  of  the  tumour  ;  at  the 
same  time,  the  operation  was  not  much  encouraged  from  the  un- 

*  Cases  and  Observations  in  Surgery,  p.  104.    London,  1806. 


232 

certainty  of  its  consequences.     The  patient  went  away ;  but  in  I 
twelve  months  he  returned,  with  a  more  decided  projection  of  the  jj 
globe,  and    a  visible  prominence  under   the  upper   lid.     Mr.  L.  i 
thought  he  could  distinguish   a  fluctuation  in  the  tumour,  and  pro-  *j 
posed  to  puncture  it,  and  see  what  it  contained.     He  did  so  with  a  i| 
lancet,  when  about  a  tablespoonful  of  clear  watery  fluid  escaped,  fl 
which  gave  relief  to  the  patient.     In  about  a  week  afterwards,  Mr. ! 
L.  observed  something  hanging  out  of  the  opening.     He  took  hold 
of  it  with  the  forceps,  and  drew  out  a  hydatid  of  considerable  size. 
In  a  few  days,  more  came  out,  after  which  Mr.  L.  injected  tepid 
water  into  the  aperture,  and  thus  brought  out  half  a  teacupful  of 
hydatids  of  various  sizes.      The  cyst  inflamed  and  suppurated, 
then  collapsed  and  closed.     The  eye  returned  into  the  orbit,  but 
continued  amaurotic.     The  patient,  fieed  from  great  local  suffer- 
ing and  severe  headach,  regained  his  health  and  strength,  and 
continued  well.* 

3.  Partial  extirpation  of  encysted  tumours.     This  is  another 
method  of  treatment  which  has  been  adopted  on  account  of  the  j 
difficulty  of  removing  the  cyst  in  an  entire  state,  and  the  danger  of  f' 
injuring  important  parts  when  the  disease  reaches  deep  into  the 
orbit.     The  front  of  the  tumour  being  exposed  in  the  usual  way, 
the  cyst  is  laid  hold  of  with  a  pair  of  hooked  forceps,  or  any  other 
suitable  instrument,  and  as  much  of  it  is  removed  as  can  convenient-  i 
ly  be  brought  within  the  grasp  of  the  scissors.     The  portion  of  the 
cyst  which  is  left  inflames,  the  external  wound  heals  up  more  or 
less  promptly,  and  in  some  cases  there  is  no  farther  trouble  experi- 
enced ;  but  more  frequently  the  wound  opens  repeatedly,  till  the 
cyst,  destroyed  by  suppuration,  is  completely  discharged. 

Case  1.  Donald  M'Kinnis,  aged  18  years,  was  admitted  into  the 
Glasgow  Eye  Infirmary,  under  the  care  of  Dr.  Monteath,  on  the 
28th  of  Sept.  1827,  on  account  of  a  soft  tumour  which,  since  in- 
fancy, had  been  observed  to  project  from  the  right  orbit,  immediate- 
ly above  the  tendon  of  the  orbicularis  palpebrarum.  Its  projecting 
part  w^as  as  large  as  a  middle-sized  gooseberry,  and  as  far  as  could 
be  judged,  the  tumour  dipped  deep  into  the  orbit.  The  eyeball 
was  not  displaced,  nor  did  the  patient  experience  any  pain,  but  he 
was  anxious  to  have  the  tumour  removed  on  account  of  the  defor- 
mity, which  was  very  considerable.  The  integuments  were  divided 
and  dissected  back,  and  when  the  anterior  half  of  the  tumour  was 
thus  exposed,  it  was  laid  hold  of  and  excised.  The  cavity  of  the 
posterior  half  could  now  be  distinctly  seen,  dipping  nearly  an  inch 
into  the  orbit,  close  to  its  internal  wall.  It  was  evident  tiiat  this 
part  of  the  cyst  could  not  be  removed,  even  by  a  laborious  dissection. 
The  whole  cavity  was  therefore  rubbed  over  with  nitrate  of  silver, 
and  then  stuffed  gently  with  lint,  over  which  a  compress  and  band- 
age   were  applied.     Very  httle  inflammation  succeeded  the  opera- 

*  Lectures  in  the  Lancet,  Vol.  x.  p.  387.     London,  1826. 


233 

tion.  The  cavity  contracted  from  day  to  day,  and  was  very  soon 
completely  obliterated,  leaving  no  deformity. 

Case  2.  The  following  case  will  illustrate  some  of  the  dangers 
attendant  even  on  the  simple  operation  of  partial  extii-pation. 
Agnes  Crawford,  aged  14  years,  was  admitted  a  patient  at  the 
Glasgow  Eye  Infirmary,  under  the  care  of  Dr.  Monteath,  on  the  24th 
October  1827.  For  six  years,  a  tumour  had  been  observed  to  pro- 
ject from  the  right  orbit,  pushing  the  upper  eyelid  before  it,  and 
most  protuberant  about  mid-way  between  the  tarsal  border  of  the 
eyelid  and  the  bony  edge  of  the  orbit.  The  greatest  projection  of 
the  tumour  was  at  the  upper  and  inner  part  of  the  orbit,  so 
that  the  eye  was  forced  downwards  and  outwards.  The  part  of 
the  tumour  which  appeared  externally  was  as  large  as  a  green- 
gage plum,  and,  from  the  very  great  displacement  of  the  eyeball, 
it  was  concluded  that  the  portion  lying  within  the  orbit  was  also 
large  and  extended  deep.  The  skin,  covering  the  tumour,  had  a 
dirty  livid  colour.  On  partially  everting  the  eyelids,  the  inferior 
part  of  the  tumour  was  seen  bulging  through  the  conjunctiva.  The 
girl  suffered  no  pain.  The  vision  of  the  eye  was  perfect,  and  the 
tunics  free  from  inflammation.  Though  the  eye  was  turned  very 
much  to  the  right  side,  she  had  no  diplopia.  She  enjoyed  good 
health.  She  had  never  menstruated.  The  tumour  had  been  re- 
peatedly punctured,  and  at  one  time  a  thread  had  been  drawn 
through  it  and  worn  for  some  time,  without  producing  either  good 
or  bad  effects. 

On  the  28th  of  October,  after  low  diet  for  three  or  four  days,  and 
two  doses  of  laxative  medicine,  the  patient  was  laid  on  a  table,  and 
an  incision,  nearly  two  inches  long,  made  in  the  direction  of  the 
fibres  of  the  orbicularis  palpebrarum.  The  integuments  were 
dissected  back  with  a  scalpel  and  a  blunt  silver  knife,  till  more 
,han  the  anterior  half  of  the  tumour  was  exposed.  This  was  now 
lut  away  with  the  scissors.  An  immense  discharge  of  fluid  imme- 
diately took  place  from  the  sac,  of  the  appearance  of  dark  blood. 
This  was  followed  by  very  considerable  haemorrhage  from  the 
Dottom  of  the  orbit.  Dr.  M.  thrust  his  finger  to  the  bottom  of  the 
Drbit,  and  making  pressure  soon  stopped  the  violence  of  the  bleed- 
ing. Cold  water  was  next  injected  for  about  a  minute,  by  means 
of  a  syringe,  deep  into  the  orbit,  which  caused  the  bleeding  to 
cease.  Examination  with  the  finger  clearly  demonstrated  that  the 
iumour  had  extended  to  the  very  bottom  of  the  orbit,  and  even  oc- 
cupied there  much  space.  It  was  therefore  impossible  to  dissect 
out  the  posterior  part  of  the  cyst,  so  that  it  was  merely  stuffed  mod- 
erately with  a  strip  of  hnt.  Another  strip  was  placed  between  the 
lips  of  the  wound,  to  prevent  adhesion.  A  compress  was  laid  over 
'all,  and  the  eyes  shaded.  Before  the  patient  had  left  the  operation, 
table,  the  eyeball  had  retreated  very  considerably  into  its  natural 
position. 

Next  day,  the  whole  of  the  upper  eyelid  was  red  and  much  swoln. 
30 


234 

The  patient  complained  of  headach,  and  her  pulse  was  112.  Ten  , 
leeches  weiej  ordered  round  the  orbit ;  after  which,  an  emolUent 
poultice  w^as  applied,  and  she  had  a  dose  of  castor  oil.  On  the  third  , 
day  after  the  operation,  the  report  states  that  the  leeches  had  bled 
freely  ;  but  that  the  tumefaction  having,  upon  the  whole,  increased, 
as  well  as  the  headach  and  fever,  the  tent  of  hnt  was  withdrawn. 
She  had  suffered  much  during  the  night,  the  pain  being  pulsating 
and  constant,  both  in  the  eye  and  head.  In  the  morning,  she  had 
been  seized  with  vomiting.  The  pulse  was  still  above  100.  Tongue 
white.  The  tumefaction  was  now  so  much  increased,  that  the  ex- 
ophthalmos was  greater  than  before  the  operation.  The  eyeball 
being  chemosed,  a  portion  of  the  swollen  conjunctiva  was  excised. 
A  probe  was  passed  through  the  wound  to  the  bottom  of  the  orbit, 
but  no  retained  blood  nor  pus  was  discharged.  A  small  portion  of 
sloughy  matter,  apparently  part  of  the  cyst,  was  extracted  from  the 
wound,  at  the  mouth  of  Vv'hich  it  presented.  Twelve  ounces  of 
blood  were  taken  from  the  arm  at  noon,  and  six  more  at  7  p.  m. 
On  both  occasions  she  became  faintish.  The  blood  was  buffy. 
The  pulse  fell  a  Uttle,  became  softer,  and  she  felt  relieved.  The 
poultice  was  continued,  and  she  was  ordered  a  dose  of  Epsom  salts 
in  civided  quantities,  which  operated  freely  in  the  nigiit,  and  dis- 
turbed her  sleep.  She  had  much  less  pain  than  during  the  previous 
night.  Next  day,  the  4th  after  the  operation,  the  pulse  was  about 
90  and  soft,  the  tumefaction  of  the  eyelids,  of  a  deep  red  colour, 
and  very  sensible  to  the  touch,  was  increased  to  the  bulk  of  the 
half  of  a  middle-sized  apple,  the  greater  part  of  the  swelling  being 
formed  of  the  upper  eyelid ;  the  chemosed  conjunctiva  projected 
from  between  the  aperture  of  the  lids ;  the  cornea  continued  trans- 
parent, and  vision  was,  as  yet,  good.  Her  thirst  had  been  immod- 
erate for  the  last  three  days,  and  still  continued.  She  had  frequent 
transient  chiils  through  the  course  of  this  da)^  Upon  the  whole, 
the  pain  of  the  eye  and  head  were  less  than  in  the  preceding  da)^ 
She  was  ordered  a  draught,  with  twenty-five  drops  of  laudanum, 
and  the  poultice  was  continued. 

For  two  days,  the  tumefaction  of  the  lids  increased,  particularly 
of  the  lower,  which  became  so  broad  as  to  reach  as  low  as  the 
opening  of  the  nostril.  The  swelling  was  indeed  enormous,  and 
the  whole  of  it  very  tender  to  the  touch.  The  cornea  could  with 
difficulty  be  seen,  being  overlapped  by  the  chemosed  conjunctiva. 
So  far  as  it  could  be  seen,  it  was  transparent,  but  the  pupil  appeared 
enlarged,  and  that  she  said  she  could  not  see. 

From  the  4th  till  the  8th  day  after  the  operation,  the  pulse  va- 
ried from  75  to  90 ;  the  thirst  gradually  ceased;  there  was  some 
return  of  appetite ;  and  the  headach  and  pain  of  the  eye  declined, 
so  that  by  the  8th  day  they  were  nearly  gone.  The  bowels  Avere 
gently  purged  with  Epsom  salts,  and  she  had  an  anodyne  each 
night  with  much  benefit.  On  the  7th  and  8th  days,  the  wound  dis-', 
charged  matter  pretty  freely.     Both  eyehds  had  by  this  time  become ' 


235 

i  softer,  and  much  less  swollen.     On  the  8th  clay,  it  was  observed 
that  pus  had  made  its  way  from  the  bottom  of  the  orbit,  through 
I  two  apertures  in  the  conjunctiva,  where  it  is  reflected  from  the  lower 
'  eyelid  to  the  eyeball,  near  the  nasal  canthus.     For  some  days  pre- 
viously to  this,  the  poultice  had  been  discontinued,  and  the  eyelids 
covered  with  lint  smeared  with  simple  ointment.     The  draught 
was  now  omitted.     On  the  2Sth  of  January  1828,  the  report  states 
that  the  incision  had  been  completely  closed  for  some  time,  and 
'  that  the  eye  had  retired  more  into  its  proper  situation.     The  pupil, 
however,  continued  dilated,  and  there  was  no  return  of  vision. 
I  The  patient  was  free  from  pain,  and  her  general  health  was  im- 
proving. 

I  On  the  8th  of  February,  the  eye  was  still  more  in  its  natural 
|iplace,  and  its  power  of  motion  increased,  but  no  renewal  of  vision. 
1  The  patient  now  left  the  Infirmary  for  her  home  in  the  country, 
tand  in  a  few  months  died  of  phthisis  pulmonalis. 

4.  Total  extirpatio7i  of  encysted  tumours.  The  complete 
extirpation  of  an  orbital  encysted  tumour  is  an  operation  almost 
[always  attended  with  considerable  difficulty.  The  flow  of  blood, 
the  danger  of  rupturing  the  cyst,  the  instant  escape  of  its  contents 
[if  it  be  accidentally  torn  or  wounded,  the  almost  impossibility  of 
jremoving  it  m  the  collapsed  state,  and  the  great  depth  to  which  the 
I  cyst  often  extends  within  the  orbit,  are  the  circumstances  which 
[have  led  to  the  practices  of  puncture  and  partial  extirpation.  The 
[total  removal,  however,  of  the  cyst,  is  much  more  satisfactory.  This 
ioperatioa  is  generally  performed  by  making  a  transverse  incision 
j  through  the  skin  of  one  or  other  eyelid,  parallel  to  the  fibres  of  the 
prbicularis  palpebrarum.  This  incision  is  not  to  be  made  freely,  but 
cautiously,  avoiding  the  lachrymal  passages  at  the  inner  canthus, 
and  taking  care  not  to  open  the  cyst,  which  is  often  almost  imme- 
3iately  under  the  skin.  The  cellular  substance  beneath  the  orbi- 
jularip  and  the  fibrous  layer  of  the  eyeUds  being  next  divided,  the 
annexions  of  the  cyst  are  to  be  separated.  This  is  best  effected 
3y  means  of  a  pair  of  blunt  forceps  and  a  silver  knife ;  with  the 
burner  laying  hold  of  the  cyst,  and  with  the  latter  destroying  its 
pellular  attachments.  This  being  accomphshed  as  completely 
[  ound  the  cyst  as  possible,  it  is  to  be  dragged  forwards,  and  its  pos- 
I  erior  connexions  divided  with  the  knife  or  the  scissors.  The  finger 
pught  now  to  be  introduced  into  the  cavity  left  by  the  removal  of 
I -he  tumour,  and  an  examination  made,  lest  any  indurated  attach- 
I'nents  or  roots  of  the  cyst  have  been  left.  These  are  to  be  laid  hold 
ipf,  and  extirpated  with  the  scissors. 

1  It  is  the  general  practice  to  fill  the  cavity  formerly  occupied  by 
|;he  tumour  with  lint,  but  this  does  not  appear  to  be  necessary.  We 
[  xiay  leave  it  filled  with  the  blood  which  flows  from  the  parts  which 
|we  have  divided.  Its  parietes  will  most  probably  inflame  and  sup- 
purate, and  then  gradually  contract ;  but  by  stuffing  it  with  lint, 
iwe  must  excite  additional  irritation,  the  inflammation  which  follows 


236 

is  likely  to  be  more  severe  and  extensive,  the  contents  of  the  orbit 
may  thus  be  made  to  suffer  severel}^,  the  eye  may  be  prevented,  by 
the  swelling  of  the  parts,  and  the  matting  together  which  they  are 
apt  to  suffer  from  the  inflammation,  from  retreating  into  its  natural 
place,  or  even  a  new  and  permanent  degree  of  protrusion  of  the  eye 
may  be  produced. 

Cases. — Case  1.  The  following  case,  related  by  Saint- Yves,  is 
frequently  referred  to,  and  appears  to  have  served  as  an  encouraging 
example  of  extirpation  of  an  orbital  tumour  to  several  of  his  succes- 
sors. The  patient  w^as  a  girl  of  twelve  years  of  age.  The  tumour 
was  situated  below  the  eyeball,  so  that  it  turned  the  pupil  upwards, 
and  protruded  the  lower  lid  for  more  than  half  an  inch.  It  ex- 
tended towards  the  cheek  for  the  breadth  of  an  inch.  Saint- Yves 
divided  the  skin  and  the  orbicularis  palpebrarum  by  a  similunar  in- 
cision, extending  the  whole  length  of  the  tumour ;  he  then  laid 
hold  of  it  with  a  hook,  separated  it  from  its  attachments  with  a 
bistoury,  and  removed  it.  With  the  ssissors,  he  next  cut  away  its 
root,  which  was  hard  and  coriaceous.  In  thirteen  days,  the  wound 
was  healed.  The  eye  returned  to  its  place,  and  the  patient  saw^ 
with  it  as  with  the  other.  The  tumour  presented  three  cavities. 
That  which  lay  next  the  skin  contained  a  purulent  fluid  ;  the  sec- 
ond was  filled  with  a  thicker  matter,  partly  calcareous ;  and  the' 
contents  of  the  third  resembled  w^hite  of  egg* 

Case  2.  A  laborious  country-man  was  attacked  with  pain,  and 
dimness  of  sight,  in  one  of  his  eyes.  These  symptoms  did  not  at- 
tract any  particular  attention  for  two  or  three  years,  when  he  be- 
came quite  blind  of  the  eye,  the  globe  being  at  the  same  time  greatly 
protruded,  and  the  lower  lid  everted.  Many  surgeons,  both  in  town 
and  country,  who  w^ere  consulted,  dissuaded  him  from  submitting 
to  any  operation,  being  apprehensive  that  his  complaint,  if  not  al- 
ready cancerous,  was  likely  to  become  so  by  meddhng  with  it.  He 
was  therefore  urged  not  to  hazard  the  danger  of  any  operation,  see- 
ing that  his  disease  did  not  render  life  intolerable,  but  might  be  sup- 
ported W'ithout  farther  inconvenience  than  the  want  of  sight  in  the 
eye,  and  its  unseemliness  from  being  so  far  thrust  out  of  its  socket. 
He  was  recommended,  however,  to  consult  Mr.  Ingram,  a  sur- 
geon in  London,  w^ho  on  carefully  examining  the^  case,  imagined 
that  he  felt,  on  pressure,  a  resisting  fluid  under  the  eye,  and  formed 
the  opinion  that  this  fluid  was  contained  in  a  cyst,  detached  from 
the  lachrymal  gland.  He  therefore  gave  encouragement  to  attempt 
the  man's  relief  by  an  operation.  Mr.  Bromfield  approved  of  this 
proposal,  and  with  Mr.  Ingram's  assistance,  performed  the  following 
operation.  He  pressed  upwards  the  distorted  lower  lid,  till  it  was 
brought  as  near  as  possible  to  its  natural  position.  While  it  was 
thus  held  tight,  Mr.  B.  cut  through  the  integuments  into  the  lower 
part  of  the  orbit  under  the  conjunctiva,  till  an  aperture  w'as  made 

•  Nouveau  Traite  des  Maladies  des  Yeux,  p.  147.    Paris,  1722. 


237 

sufficient  to  peiinit  the  introduction  of  the  fing-er,  so  as  to  direct  a 
sharp-pointed  scalpel,  with  which  he  perforated  the  tumour.  Im- 
mediately, a  thin  pellucid  liquor  was  discharged,  not  far  short  in 
quantity  of  a  small  wine  glassful.  Here  Mr.  B.  paused,  to  give  the 
patient  a  little  water  to  cleanse  his  mouth  from  the  blood,  and  ob- 
served, that  his  business  was  not  more  than  half  done,  until  he  could 
extract  the  cyst  which  had  contained  the  water.  He  therefore  in- 
troduced two  small  hooked  instruments  to  catch  hold  of  it,  and  took 
it  completely  out.  The  wound  was  filled  with  lint,  and  dry  dress- 
ings, and  these  were  secured  by  a  proper  bandage.  Within  less 
than  twenty-four  hours  the  patient's  head  and  neck  were  swelled 
to  a  prodigious  size.  This  was,  after  some  time,  removed,  by  dress- 
ing it  very  lightly  with  dry  hnt,  and  by  a  few  gentle  purges. 
Treated  as  a  common  superficial  wound,  in  less  than  a  month  the 
whole  was  healed,  and  the  man  sent  home  perfectly  satisfied.  Mr. 
I.  was  all  along,  even  before  the  operation,  confident,  that  the  over- 
stretched muscles  of  the  eye  would,  in  time,  recover  their  natural 
power,  that  the  globe  of  the  eye  itself  would  consequently  be  in- 
cluded within  its  socket  without  leaving  any  outward  blemish,  and 
that  even  the  sight  would,  to  a  certain  degree,  return.  Dr.  Brock- 
lesby,  who  relates  the  case,  owns  that  he  gave  not  much  credit  to 
€ill  this,  till  five  months  after  the  man  went  home,  when,  being  in 
the  country,  he  sent  for  him  to  satisfy  his  curiosity.  When  he  saw 
him,  he  scarce  knew  him  again  ;  for  his  eyelid  had  fully  recovered 
its  natural  position  and  functions.  About  a  month  before  Dr.  B. 
saw  him,  the  eye  began  to  be  sensible  of  the  difference  between 
darkness  and  bright  sunshine,  and  ever  since  that  period  its  power 
of  perception  had  become  gradually  strengthened.* 

Case  3.  Thomas  Heard,  a  healthy-looking  young  man  of  17, 
was  admitted  an  in-patient  of  the  Exeter  Eye  Infirmary,  under 
the  care  of  Mr.  Barnes,  on  account  of  a  tumour  which  completely 
obstructed  the  sight  of  his  left  eye.  The  tumour  was  situated 
beneath  the  eye,  occupying  a  ver}'^  considerable  portion  of  the 
orbit ;  the  eye  in  consequence  was  pushed  into  the  upper  part  of 
that  <-avity,  so  as  to  be  almost  wholly  hidden  behind  the  upper  hd. 
On  tracing  it  backwards,  the  tumour  appealed  to  extend  to  a  very 
considerable  depth ;  and  it  projected  so  much  in  front,  as  to  con- 
stitute a  very  striking  deformity.  Anteriorly  it  was  rounded  in 
form.  A  superficial  groove,  running  obliquely  across  its  upper  sur- 
face, formed  a  slight  line  of  division  between  the  more  prominent 
and  movable  part  of  the  swelling,  and  that  more  immediately  under 
the  eyeball.  The  ciliary  edge  of  the  lower  tarsus,  with  a  few  scat- 
tered hairs  in  it,  crossed  the  front  of  the  tumour  rather  above  its 
middle;  the  conjunctiva,  drawn  forwards  from  the  eyeball,  greatly 
stretched,  but  not  apparently  much  altered  in  structure,  investing 
it  above ;  and  a  thin  skin  of  a  deep  red,  loaded  with  purple  vessels, 

*  Medical  Observations  and  Inquiries,  Vol.  iv.  p.  371.     London,  1772. 


238 

covering  it  below  ;  bat  neither  of  them  closel)^  adherent  to  it.  The 
portion  of  the  tumour  in  front,  was  soft,  and  could  be  moulded  into 
different  shapes  by  the  fingers ;  the  posterior  division  felt  more 
elastic.  By  an  effort,  the  patient  could  raise  the  upper  eyelid  a 
little,  but  not  his^h  enough  to  discover  even  the  lower  edge  of  the 
cornea.  By  lifting  it  with  the  finger,  a  portion  of  the  pupil  might 
be  exposed,  and  he  could  then  distinguish  objects  partially.  The 
eye  was  apparently  perfect,  but  he  had  scarcely  any  power  of  mov- 
ing it.  The  swelling  was  first  observed  in  early  infancy,  and  was 
at  that  time  not  much  larger  than  a  pea.  It  incji-eased  ]3ut  slowly, 
until  about  four  or  five  years  before  his  admission  into  the  Infirma- 
ry, when  it  began  evidently  to  enlarge,  and  for  some  time  grew 
rapidly.  More  lately  it  had  not  advanced  much.  It  caused  no 
pain,  but  as  it  was  a  great  deformity,  was  still  enlarging,  and  by 
its  presence  rendered  the  eye  useless,  it  was  thought  advisable  to 
remove  it. 

Id  the  operation,  a  division  was  made  of  the  inferior  oblique 
muscle  of  the  eye,  which  appeared  stretched  across  the  front  of  the 
tumour,  having  been  pushed  before  it,  in  its  progress  from  the 
deeper  parts  of  the  orbit.  The  sac  adhered  firmly  to  the  outer 
angle,  and  part  of  the  lower  edge  of  the  orbit ;  in  most  other  points, 
it  was  but  loosely  connected  with  the  surrounding  parts.  It  was 
found  to  extend  almost  to  the  bottom  of  the  orbit,  and  to  occupy 
more  of  it  than  did  t!ie  eye  itself.  As  it  was  impossible  to  proceed 
in  the  dissection  far  within  tlial  cavity,  without  greatly  endanger- 
ing the  eye,  on  account  of  the  very  narrow  space  between  it  and 
the  posterior  division  of  the  swelhng,  the  contents  cf  the  latter  were 
partially  evacuated,  to  obtain  room,  and  the  sac  cautiously  separated 
from  its  deeper  attachments.  Towards  the  posterior  point,  on  the 
inner  side,  and  more  than  an  inch  from  the  edge  of  the  orbit,  the 
sac  felt  as  if  it  eurbraced  a  shar]:)  bony  process,  arising  from  about 
the  line  of  junction  between  the  ethmoid  and  superior  maxillary 
bones.  Unwilling  to  proceed  at  hazard,  the  operator  cut  oft'  the 
cyst  close  up  to  this  projection,  that  its  nature  and  connexions 
might  be  examined  before  an  attempt  was  made  to  remove  it.  It 
appeared  to  be  formed  of  bone,  terminating  in  a  sharp  point,  and 
proiecting  nearly  in  a  perpendicular  direction  into  the  cavity  of  the 
orbit.  It  was  slightly  movable,  as  if  attached  to  the  periosteum 
only;  and  was  removed  without  much  difficulty,  together  with 
the  remains  of  the  sac  which  adhered  to  it.  On  examination,  it 
was  found  to  be  a  tooth,  resembling  in  form  and  size,  the  supernu- 
merary teeth  sometimes  found  in  the  palate.  The  part  which  \no- 
jected  into  the  sac  was  conical,  and  covered  by  smooth,  shining, 
white  enamel ;  the  sac  firmly  adhered  round  a  contracted  portion 
at  the  base  of  the  cone,  resembling  the  neck  of  a  tooth  ;  and  with- 
out the  sac,  there  was  the  appearance  of  a  root,  truncated  obliquely, 
with  a  passage  in  the  centre,  evidently  containing  blood-vessels. 
It  was  by  this  part  that  it  W'as  connected  with  the  floor  of  the  orbit. 


239 

I 
The  patient  had  a  complete  natural  set  of  teeth,  though  many  of 

them  were  disposed  irregularly. 

The  extirpated  tumour  was  found  to  be  made  up  of  two  cysts, 
separable  by  dissection,  at  the  groove  already  mentioned,  to  some 
depth  all  round,  but  indissolubly  united  in  the  centre.  That  in 
front  allowed  the  colour  of  its  contents  to  be  distinguished  through 
it.  The  posterior  sac  was  thicker  and  more  vascular.  The  inte- 
rior surface  of  that  in  front  was  rough,  with  here  and  there  a  chalky 
matter  adhering  to  it.  It  contained  a  compact  lardaceous  yellow 
substance.  The  inner  surface  of  the  posterior  sac  was  smooth,  ex- 
cepting a  part  near  the  tooth,  where  it  had  much  the  appearance 
of  coarse  skin  with  many  pores  in  it.  The  contents  were  partly  a 
whey-coloured  fluid,  and  partly  a  yellow  curdy  substance.  The 
eye  did  not  in  the  least  drop  on  the  removal  of  the  tumour  ;  and 
the  large  cavity  which  this  had  occupied,  was  filled  with  pieces  of 
soft  sponge,  dipped  in  oil.  On  removing  the  last  piece  of  sponge, 
on  the  seventh  day  after  the  operation,  the  cavity  was  found  to  be 
every  where  covered  by  healthy  granulations.  The  opening  con- 
tracted rapidly,  and  the  eye  sunk  fast,  so  that  within  a  fortnight  it 
was  nearly  on  a  level  with  the  other.  The  patient  was  discharged  in 
the  beginning  of  January,  with  the  wound  perfectly  healed.  The 
lower  lid  did  not,  at  that  time,  cover  so  much  of  the  eyeball  as  it 
does  naturally  ;  and  in  one  spot  the  ciliary  edge  was  a  little  invert- 
ed. He  had  the  power  of  moving  it  slightly,  but  he  could  not 
raise  it  high  enough  to  bring  it  into  accurate  apposition  with  the 
upper.  The  lachrymal  canal  of  each  lid  was  pervious  to  fluids, 
which  passed  freely  into  the  nose  by  means  of  a  syringe.  There 
was  a  considerable  hollow  above  the  eyeball ;  and  the  eye  was  not 
quite  in  a  line  with  the  other,  but  rather  above  it.  He  could  not 
move  it  at  all  downwards,  or  freely  in  any  direction.  With  the 
exception  of  this  inconvenience,  he  enjoyed  with  it  perfect  vision.* 

Case  4.  The  eye  of  a  man,  of  29  years  of  age,  was  pressed  in- 
wards and  downwards  by  a  tumour  which  occupied  the  upper  and 
outer  side  of  the  orbit.  The  tumour  fluctuated,  and  was  very 
prominent.  In  consequence  of  previous  inflammation,  the  cornea 
was  opaque,  and  the  eyelids  were  united  to  the  eyeball.  Langen- 
beck  divided  the  upper  lid,  over  the  tumour,  which,  as  soon  as  it 
was  laid  bare,  presented  the  appearance  of  a  shining  transparent 
cyst.  He  removed  it  perfectly  entire.  It  was  about  the  size  of  a 
pigeon's  egg,  and  filled  with  fluid.  The  edges  of  the  wound  were 
brought  together,  and  after  it  was  healed,  the  morbid  union  of  the 
lids  to  the  ball  of  the  eye  was  divided,  so  that  the  eye  was  restored 
to  its  natural  place  and  power  of  motion.t 

*  Medico-Chirurgical  Transactions,  Vol.  iv.  p.  316.     London,  1813. 
t  Neue  Bibliothek  fur  die  Chirurgie  und  Ophthalmologic.     Vol.  ii.  p.  40.  Hano- 
ver, 1819. 


240 


SECTION  V. ORBITAL    ANEURISMS. 

1.    Orbital  Aneurism  hy  Anastomosis. 

The  disease,  so  admirably  described  by  Mr.  John  Bell,  under  the 
name  of  aneurism  from  anastomosis,  does  not  appear  to  arise 
from  any  original  malformation,  such  as  we  observe  in  nsevus  ma- 
ternus,  although  this  congenital  structure  is  apt,  as  has  been  already 
explained,*  to  assume,  in  a  considerable  measure,  the  characters  of 
this  kind  of  aneurism.  The  disease  described  by  Mr.  Bell,  often 
begins  in  apparently  healthy  adults,  from  sudden  and  hidden 
causes ;  it  is  not  confined  to  the  skin,  or  subcutaneous  cellular 
membrane,  but  affects  indiscriminately  all  parts  of  the  body,  and 
brings  on  complicated  morbid  phenomena  even  among  the  viscera. 
Several  cases  are  now  recorded,  in  which  aneurism  by  anastomosis 
has  arisen  within  the  orbit,  characterised  by  pain  in  the  eye  and 
head,  a  peculiar  sensation  compared  to  a  snap  or  crack,  followed  by 
a  whizzing  noise  in  the  head,  blindness,  protrusion  and  pulsation 
of  the  eye,  and  pulsatory  or  aneurismal  sweUings  between  the  eye 
and  the  orbit.  The  instances  which  have  occurred  of  this  disease 
in  the  orbit  have  been  too  few,  to  permit  us  to  describe  from  actual 
observation  its  ultimate  effects  and  termination  ;  but  reasoning 
from  the  history  of  aneurisms  by  anastomosis  in  other  parts  of  the 
body,  we  cannot  doubt  that  the  progress  of  the  disease  would  be 
equally  rapid  in  this  situation,  the  bleedings,  if  the  complaint  were 
neglected,  alarming  and  dangerous,  and  the  issue  fatal. 

Mr.  Abernethy  has  related  an  interesting  case  of  neevus  mater- 
nus  of  tlie  upper  eyelid,  in  which  the  disease  extended  also  into  the 
orbit,  and  of  which  a  cure  was  effected  by  the  simple  abstraction  of 
heat,  by  means  of  folded  hnen,  wet  with  a  saturated  solution  of 
alum  in  rose  water,  and  kept  constantly  applied  over  the  tumour.t 
This  mode  of  treatment,  however,  and  also  that  of  pressure  on  the 
aneurism,  are  evidently  quite  inapplicable  when  this  disease  is  situ- 
ated deep  within  the  orbit.  Neither  can  excision  be  had  recourse 
to  in  such  a  case,  unless  we  resolve  at  once  to  remove  the  whole 
contents  of  the  orbit ;  and  even  were  the  patient  ready  to  submit  to 
this  operation,  could  we  with  safety  attempt  it,  knowing,  as  we  do 
from  the  recorded  histories  of  many  aneurisms  by  anastomosis,  the 
innumerable  sources  by  which  such  tumours  are  supplied  with 
blood,  the  great  dilatation  which  the  neighbouring  blood  vessels 
commonly  present,  and  the  difiiculty  which  has  often  been  expe- 
rienced in  arresting  the  heemorrhage  attendant  on  attempts  to  ex- 
tirpate tumours  of  this  nature. 

The  only  other  m^ode  of  treatment  likely  to  impede  the  progress  of 
an  anastomotic  aneurism  within  the  orbit,  is  diminution  of  the  force 

*  See  p.  127. 

t  Surgical  Observations  on  Injuries  of  the  Head  ;  and  on  Miscellaneous  Subjects 
p.  228.    London,  1815. 


241 

of  the  circulation  through  the  tumour,  by  applying  a  ligature  on 
the  common  carotid  artery.  We  owe  the  first  proof  of  the  efficacy 
of  this  plan,  not  only  in  preventing  the  increase,  but  even  in  effect- 
ing the  cure  of  this  disease,  to  Mr,  Travers.  His  example  has  been 
followed  by  Mr.  Dalrymple  of  Norwich,  who  has  published  a 
second  highly  interesting  instance  of  the  efficacy  of  the  operation  ; 
while,  still  more  recently,  Mr.  Wardrop  has  demonstrated  that 
similar  good  effects  may  be  expected  from  tying  the  carotid,  in  cases 
of  extensive  neevus  occupying  the  external  parts  of  the  face.*  The 
cases  by  Mr.  Travers  and  Mr.  Dalrymple  are  valuable,  not  only 
as  proofs  of  the  efficacy  of  the  mode  of  treatment,  but  as  illustra- 
tions of  the  origin,  progress,  and  effects  of  the  disease.  I  shall 
therefore  quote  them,  almost  without  abridgment.  At  the  same 
time,  there  is  a  suggestion  made  by  Mr.  Hodgson,t  which  is  worthy 
of  notice,  namely,  that  in  similar  cases  it  would  be  advisable  to  aid 
the  process  of  cure  after  the  operation,  by  depletion  and  abstinence. 
In  Mr.  Travers'  patient,  the  diminution  of  the  tumour  was  very 
remarkable  after  violent  discharges  of  blood  from  the  uterus.  A 
very  spare  diet,  and  the  avoidance  of  all  violent  exercise,  in  con- 
junction with  repeated  blood-letting,  have  been  known  to  prove 
successful  in  the  cure  of  a  carotid  aneurism,  +  and  the  observance 
of  a  similar  legimen  must  be  highly  proper  after  the  application  of 
1  a  ligature  on  the  carotid  in  any  case  of  aneurism  by  anastomosis. 

Case.  Frances  Stoffell,  aged  34.  a  healthy  active  woman,  the 
mother  of  five  children,  on  the  evening  of  28th  of  December,  1804, 
being  some  months  advanced  in  pregnancy,  felt  a  sudden  snap  on 
the  left  side  of  her  forehead,  attended  with  pain,  and  followed  by  a 
copious  effusion  of  a  limpid  fluid  into  the  cellular  substance  of  the 
eyelids  on  the  same  side.  For  some  days  preceding,  she  had  com- 
plained of  a  severe  pain  in  the  head,  which  was  now  increased  to 
so  great  a  degree,  that  for  the  space  of  a  week  she  was  unable  to  raise 
it  from  the  pillow.  The  oedematous  swelling  surrounding  the  orbit 
was  reduced  by  punctures ;  an  issue  was  set  in  the  temple  for  a 
smart  attack  of  ophthalmia  which  supervened,  and  leeches  and 
cold  washes  were  applied.  She  now  first  perceived  a  protrusion 
of  the  globe  of  the  eye,  with  dimness  of  sight,  and  the  ap- 
pearance of  a  circumscribed  tumour,  elastic  to  the  touch,  about  as 
large  as  a  hazel-nut,  upon  the  infra-orbitary  ridge.  Another  softer 
and  more  diffused  swelling  arose  at  the  same  time  above  the  tendon 
of  the  orbicularis  palpebrarum.  The  lower  tumour  communicated 
both  to  the  sight  and  the  touch,  the  pulse  of  the  larger  arteries  ;  the 
upper  gave  the  sensation  of  a  strong  vibratory  thrill.  The  swellings 
grew  slowly,  and  the  skin  between  the  eyes  and  that  of  the  lower 
eyelid  became  puffed  and  thickened.     The  globe  of  the  eye  was 

*  See  p.  133. 

t  Treatise  on  the  Diseases  of  Arteries  and  Veins,  p.  446.     London,  1815. 
t  Memoires  de  I' Academie  des  Sciences,' pour  1765.    Tome  xxxvii.  p.  758.    Am- 
Bterdam,  1771. 

31 


242 

gradually  fciced  upwards  and  outwards,  and  its  motions  were 
consideraiily  impeded.  She  had  a  constant  noise  in  her  head, 
which,  to  her  sensation,  exactly  resembled  the  blowing  of  a  pair  of 
bellows.  Tlie  pulsatory  motion  of  the  tumours  was  much  increased 
by  agitation  of  mind,  or  strong  exercise  of  body,  but  the  most  dis- 
tressing of  her  symptoms  was  a  cold  obtuse  pain  in  the  crown  of 
the  head,  occasionally  shooting  across  the  forehead  and  temples. 
She  was  compelled  to  rest  the  left  side  of  her  head  on  her  hand 
when  in  the  recumbent  posture,  and  found  the  beating  and  noise 
to  increase  sensibly  when  her  head  was  low  and  unsupported. 

Such  was  the  substance  of  the  patient's  report,  when  Mr.  Travers 
was  recjuested  to  see  her.  He  found  the  skin  in  the  region  of  the  ■■ 
orbits  morbidly  thick  and  wrinkled,  the  eyebrow  of  the  diseased 
side  pushed  two  or  three  lines  above  the  level  of  the  opposite  one, 
and  the  hollow  of  the  orbit  lost  from  the  elevation  of  the  globe  of 
the  eye.  The  upper  half  of  the  inner  canlhus  was  filled  by  the 
thrilling  tumour,  which  afforded  a  loose  woolly  sensation  to  the 
touch,  was  very  compressible,  and  when  firmly  compressed,  was 
felt  slighily  to  pulsate.  The  veins  of  the  upper  lid  and  on  the  sides 
of  the  nose  were  varicose,  and  the  skin  was  much  pursed  over  the 
lachrymal  sac.  The  lower  tumour,  which  projected  above  the 
infra-orbitary  foramen  was  of  a  conical  shape,  firm,  but  elastic  to  the 
touch.  It  could  be  emptied,  or  pressed  back  into  the  orbit,  but  the 
pulsation  then  became  violent;  and  from  the  increased  pressure  of 
the  globe  upon  the  roof  and  side  of  the  orbit,  the  pain  was  insup- 
portable. Careful  compression  of  the  temporal,  angular,  and  max- 
illary arteries,  produced  no  effect  on  the  aneurism.  Upon  applying 
the  thumb  to  the  trunk  of  the  common  carotid,  Mr.  T.  found  the 
pulsation  to  cease  altogether,  and  the  whiz  of  the  little  swelling  to 
be  rendered  so  exceedingly  faint,  that  it  was  difficult  to  determine 
whether  it  continued  or  not.  The  recent  increase  of  puffiness  in 
the  skin  over  the  root  of  the  nose,  and  below  the  inner  angle  of  the 
opposite  eye,  had  given  alarm  to  the  patient  and  her  friends,  who 
feared,  not  without  some  appearance  of  reason,  a  similar  affection 
of  the  ri^ht  orbit. 

Mr.  T.  felt  persuaded  that  this  disease  could  be  no  other  than 
aneurism  by  anastomosis.  Indeed,  it  bore  so  strong  a  resemblance 
in  its  principal  features  to  several  of  Mr.  John  Bell's  cases,  and  in 
particular  to  that  communicated  by  Mr.  Freer,  of  Birmingham, 
whose  patient,  refusing  assistance,  expired  of  haemorrhage,  that 
Mr.  T.  considered  the  sensible  growth  of  the  disease  an  argument 
of  sufficient  force  to  justify  any  rational  attempt  to  repress  it. 
From  the  character  of  similar  cases,  and  the  idea  which  he  had 
formed  of  this,  it  was  to  be  expected,  that  although  it  had  been 
slow  in  its  formation,  it  would  be  rapid  in  its  increase ;  and,  unlike 
the  aneurism  of  trunks,  would  resist  control  as  it  acquired  size. 
He  first  tried  the  effect  of  pressure,  but,  although  moderate,  it  could ' 
be  borne  only  for  a  very  limited  time,  by  reason  of  the  pain  attend- 


243 

irig  the  exasperated  action  of  the  arteries.  Cold  applications  had 
been  already  made  use  of  without  any  evident  advantage,  but  in- 
deed the  duration  and  aspect  of  the  disease  made  this  remedy 
appear  trifling.  Excision,  the  only  method,  of  which,  in  similar 
cases,  experience  had  confirmed  the  success,  was  clearly  imprac- 
ticable without  extirpation  of  the  eye  ;  and  from  the  great  displace- 
ment of  the  globe,  and  the  obvious  origin  of  the  disease  within  the 
orbit,  Mr.  T.  considered  the  result  of  such  an  operation  to  be  most 
precarious.  Being  satisfied  of  the  increase  of  the  disease,  knowing 
from  the  happy  precedent  of  Sir  Astley  Cooper's  first  case  of  carotid 
aneurism,  tiie  perfect  practicability,  and,  under  favourable  circum- 
stances, the  moderate  risk  of  placing  a  ligature  on  the  carotid  artery, 
and  particularly  reflecting  that  the  obstruction  of  such  a  channel, 
must,  at  all  events,  be  followed  by  a  sensible  and  permanent  dimi- 
nution of  the  impulse  of  blood  destined  to  the  disease,  Mr.  T.  tied 
the  carotid  on  the  23d  of  May,  L809. 

After  exposing  the  artery,  a  cuiTed-eyed  probe,  carrying  a  stout 
round  ligature,  was  passed  beneath  it,  and  upon  compressing  the 
vessel  with  the  fingei.,  as  it  lay  over  the  probe,  the  pulsation  of  the 
lower  tumour  immediately  ceased.  The  probe  being  cut  away, 
the  ligatures  were  drawn  apart  from  each  other,  and  tied.  Before 
she  quitted  the  table,  the  patient  observed  that  the  pain  was  numbed, 
and  that  the  noise  in  her  head  had  entirely  ceased.  The  small 
tumour  over  the  angle  of  the  eye  was  still  thrilling,  but  very  ob- 
scurely. The  ligatures  came  away  on  the  21st  and  22d  days. 
Few  symptoms  of  general  irritation  followed  the  operation.  By 
the  fifth  day,  the  pulse,  vi'hich  had  risen  to  130,  had  fallen  to  84 ; 
her  headach  had  subsided  ;  and  she  felt  comfortable  in  every  respect. 

The  following  are  the  principal  changes  which  followed  the  ope- 
ration. In  the  evening  of  the  same  day,  Mr.  T.  was  concerned  to 
find,  that  the  lower  tumour  had  already  acquired  the  thrilling 
motion  of  the  upper.  On  the  third  day,  the  tingling  or  thrilling 
sensation  was  experienced  in  both  tumours,  upon  li^ht  contact  of 
the  finger ;  if  firmly  compressed,  a  pulse  was  perceived  in  the 
lower.  On  the  fifth  day,  the  tumours  were  very  considerably 
diminished,  and  the  eye  less  prominent;  the  globe  of  the  eye  com- 
municated a  slight  pulsation ;  her  sight  was  short,  and  objects 
appeared  to  her  larger  than  natural,  and  misty.  On  the  21st  day, 
she  found  no  inconvenience  from  sitting  iip,  and  working  all  day, 
and  was  astonished  to  find  that  she  could  read  small  print,  and  do 
fine  work  with  her  right  or  sound  eye,  which  she  had  been  unable 
to  do  for  years.  By  the  end  of  the  fifth  week  she  could  perform 
all  the  duties  of  her  situation  as  well  as  before  the  operation,  and 
expressed  herself  well  satisfied  with  the  obvious  diminution  of  the 
tumour,  the  decrease  of  the  pulsation,  and  the  total  freedom  she 
enjoyed  from  pain,  which  liad  distracted  her  for  years.  Four 
months  after  the  operation,  the  tinnours  were  evidently  smaller, 
and  their  motion  materially  diminished ;  the  eye  was  less  project- 


244 

ing  ;  the  cold  dull  pain,  formerly  uninterrupted,  was  now  but  rarely 
felt ;  the  artery  of  the  left  side  was  distinguished  beating  very 
feebly  below  the  angle  of  the  jaw,  while  the  carotid  of  the  opposite 
side  contracted  with  more  than  ordinary  force. 

On  the  28th  of  October,  she  miscarried  at  the  period  of  about 
ten  weeks  after  conception.  The  haemorrhage  was  so  considerable 
as  to  induce  syncope,  and  left  her  in  a  state  of  extreme  debility. 
On  the  succeeding  morning,  it  was  observed  that  the  upper  tumour 
was  flattened,  and  the  pulsation  had  altogether  ceased.  On  the  30th, 
she  felt  pain  in  the  affected  side  of  the  head,  and  was  feverish.  In 
the  course  of  a  few  hours,  the  cellular  substance  of  the  orbit  was 
filled  with  a  serous  fluid,  precisely  as  at  the  commencement  of  the 
disease.  The  pain  was  reheved,  and  the  oedematous  swelhng,  and 
heat  of  the  surface,  were  reduced  by  a  cold  lotion.  In  the  course 
of  November,  the  pain  in  her  head  had  entirely  subsided,  but 
owing  to  her  extreme  debility  from  loss  of  blood,  she  was  subject 
to  occasional  palpitation  of  the  heart,  and  giddiness.  The  upper 
tumour,  and  the  folds  of  the  integuments  between  the  eyebrows, 
had  totally  disappeared.  The  eye  projected  less  ;  the  lower  tumour 
was  inelastic,  and  had  no  preternatural  pulsation.  In  May,  1811, 
a  knob,  of  the  size  of  a  large  pea,  over  the  inner  angle  of  the 
eye,  was  the  only  vestige  that  remained  of  the  disease.*  Nearly 
five  years  after  the  operation,  Mr.  Hodgson  had  an  opportunity  of 
examining  this  patient.  She  was  then  in  perfect  health,  and  the 
cure  of  the  aneurism  so  complete,  that  it  was  impossible  to  discov- 
er that  disease  had  existed  in  the  orbit.t 

Case  2.  On  the  24th  of  November,  1822,  Dinah  Field,  aged 
44  years,  of  a  delicate  and  sickly  habit  of  body,  came  to  Mr.  Dai- 
ry mple,  of  Norwich,  with  a  complaint  in  the  left  eye.  She  said, 
that  about  five  months  before,  being  then  pregnant  of  her  sixth 
child,  she  was  seized  in  the  middle  of  the  night,  with  an  intense 
pain  in  the  left  eyeball,  accompanied  by  a  whizzing  noise  in  the 
head,  which  grievously  distressed  her.  The  attack  was  instanta- 
neously sudden.  Hearing  a  noise,  as  of  the  cracking  of  a  whip, 
and  feeling  at  the  same  moment  an  extraordinary  kind  of  pain  in 
the  globe  of  the  left  eye,  she  awoke  in  great  alarm,  and  leaped  out 
of  bed.  About  ten  or  twelve  hours  afterwards,  the  eye  became  in- 
flamed, and  the  eyelids  so  much  swelled,  as  to  project  considerably 
beyond  the  level  of  the  upper  and  lower  orbitary  ridge.  She  also 
felt  acute  pain  over  the  whole  of  the  left  side  of  the  head  ;  while 
in  the  left  eyebrow,  and  at  the  bottom  of  the  orbit,  her  anguish 
was  scarcely  to  be  borne.  In  the  succeeding  night,  the  extreme 
violence  of  the  pain  abated,  but  the  swelling  of  the  eyelid  seemed 
rather  to  increase  ;  and  she  thought  she  felt  as  if  the  globe  of  the 
eye  was  forcibly  drawn  upwards  towards  her  forehead.  No  partic- 
ular alteration  took  place  in  the  next  seven  weeks,  at  the  end  of 

*  Medico-Chirurgical  Transactions,  Vol.  ii.  p.  1.    London,  1813. 

i  Treatise  on  the  Diseases  of  Arteries  and  Veins,  p.  446.    London,  1815. 


245 

which  she  was  delivered.  During  her  labour,  which  she  said  was 
very  severe,  there  was  projected  between  the  eyelids  a  bright  red 
tumour,  of  an  oblong  form,  which,  for  seven  or  eight  days,  gradu- 
ally enlarged,  until  it  occupied,  in  a  vertical  direction,  almost  the 
whole  space  between  the  superciliary  ridge  and  the  lower  edge  of 
the  ala  nasi,  reaching  horizontally  from  the  external  angle  of  the 
left  eye,  across  the  root  of  the  nose,  to  nearly  the  internal  canlhus 
of  the  right  eye.  In  the  course  of  her  confinement,  this  tumour 
was  punctured,  in  several  places,  by  a  surgeon  who  then  attended 
her.  It  bled  freely,  became  smaller,  and  of  a  strikingly  darker 
colour.  A  week  afterwards,  it  was  again  punctured,  and  with  sim- 
ilar results ;  and  although  the  operation  was  repeated  four  other 
times,  the  latter  incisions  afforded  no  relief.  About  two  months 
previous  to  the  appearance  of  this  swelling,  the  patient  lost  all 
power  over  the  levator  muscle  of  the  upper  eyelid  ;  but  if  the  swell- 
ing was  depressed,  and  the  lid  raised,  she  could  see  as  well  as  ever. 
She  soon,  however,  became  totally  blind  on  this  side. 

Three  or  four  months  after  Mr.  D.  first  saw  her,  he  found  that 
her  general  health  had  sensibly  declined,  and  that  the  local  affec- 
tion, now  marked  by  very  decided  characters,  was  distinctly  aneu- 
rismal.  She  had  constant  and  acute  pain,  referred  chiefly  to  the 
bottom  of  the  orbit ;  but  her  severest  suffering  was  occasioned  by 
the  increasing  noise  in  her  head,  which  she  compared  to  the 
rippling  of  water,  and  which  became  absolutely  insupportable, 
when,  b}^  any  accident,  her  head  fell  below  a  certain  level.  The 
left  eyeball  was  immovable  ;  and  either  enlarged,  or  thrust  with 
so  much  force  against  the  upper  eyelid,  as  to  cause  this  part  to 
project,  in  a  convex  form,  considerably  beyond  the  superciliary  and 
infra-orbitary  ridges.  The  eyebrow,  also,  of  the  affected  side,  rose 
somewhat  above  the  level  of  the  other.  The  external  surface  of 
the  tumid  eyelid  was,  for  the  most  part,  soft  and  elastic  to  the 
touch,  but  its  cuticle  was  remarkably  coarse,  as  was,  indeed,  the 
texture  of  the  skin  generally  in  the  vicinity  of  the  orbit. 

Deep  seated  within  the  integuments  of  the  eyelid,  a  little  towards 
the  inner  canthus  of  the  eye,  there  was  a  cluster  of  small  tumours, 
of  a  firm  and  dense  structure,  causing  great  pain  when  compressed, 
and  communicating  to  the  finger  a  pulsatory  thrill.  Interposed 
between  this  cluster  and  the  lower  edge  of  the  eyebrow,  precisely 
in  the  course  of  the  frontal  branch  of  the  ophthalmic  artery,  there 
was  a  hard  tubercular  substance,  which  rose  somewhat  higher 
above  the  general  surface  of  the  eyelid,  and  pulsated  still  more  dis- 
tinctly than  the  smaller  swellings.  The  texture  of  this  substance 
was  particularly  hard  and  compact,  and  the  slightest  pressure  upon 
it  occasioned  intolerable  pain.  The  lower  eyelid  was  everted,  and 
formed  a  bright  red  convex  tumour,  following  in  its  outline  the  di- 
rection of  the  inferior  edge  of  the  orbit,  and  reaching  from  the  ex- 
ternal commissure  of  the  eyelids  to  a  little  way  beyond  the  tendon 
of  the  orbicularis.     At  its  upper  part  it  was  covered  by  an  overlap- 


246 

ping-  of  the  upper  eyelid  which  was  paralytic,  and  entirely  conceale( 
the  globe  of  the  eye.  The  most  depending  part  of  this  tumou 
reached  to  within  a  line  of  the  infra-orbitary  foramen.  Like  thi 
tumours  at  the  upper  part  of  the  orbit,  this  sweUing  communicate( 
to  the  touch  an  aneurismal  thrill,  which  also  becanie  evident  to  th( 
sight  whenever  the  force  of  the  circulation  was  increased.  In  ad 
dilion  to  these  appearances,  immediately  above  the  nasal  third  o 
the  superciliary  ridge,  the  integuments  were  gently  elevated  into  i 
soft  ill-defined  tumour,  occupying  very  exactly  the  situation  of  cer 
tain  branches  of  the  frontal  artery,  and  pulsating  siinultaneousl) 
with  the  artery  at  the  wrist.  A  similar  elevation  of  the  skin  wa; 
perceptible  at  the  root  of  the  nose,  giving  a  faint  tremulous  motior 
to  a  finger  placed  upon  it.  When  the  globe  of  the  eye  was  un 
covered,  it  appeared,  at  first,  to  be  enlarged,  but  a  closer  inspectior 
showed  it  to  be  forcibly  thrust  forwards,  in  a  direction  somewha 
outwards  and  upwards.  A  multitude  of  enlarged  vessels  could  b( 
traced  from  the  surface  of  the  lower  tumour  to  that  portion  of  thf 
conjunctiva  which  covers  the  sclerotica.  The  cornea  retained  it- 
natural  lustre  and  transparency,  but  there  was  a  total  loss  of  powei 
in  the  iris,  and  the  pupil,  much  dilated,  was  slightly  irregular.  Be 
hind  the  lens  a  fawn-coloured  appearance  was  observed,  similar  tc 
that  represented  in  the  second  plate  of  M]\  Saunders'  posthumous 
work.  The  cutaneous  veins  of  the  face  generally  were  very  fuL 
of  blood,  and  gave  to  the  skin  of  the  left  side  of  the  face  the  com- 
plexion of  a  person  strangled.  When  strong  pressure  was  made 
upon  the  conunon  carotid  arter}',  the  tremulous  motions  of  the  tu- 
mour, situated  at  the  lower  part  of  the  oi'bit,  ceased  entirely,  but  the 
pulsations  of  the  upper  swellings  continued  in  some  degree.  The 
force  of  the  stroke  was,  indeed,  much  weakened,  but  no  pressure 
which  the  patient  was  able  to  bear,  could  entirely  suppress  it. 

At  noon,  on  the  7th  of  April,  1813,  J\Ir.  D.  tied  the  common 
trunk  of  the  left  carotid  artery.  The  effects  of  the  operation  were 
immediate  and  decisive.  As  soon  as  the  ligatures  were  tied,  the 
pulsatory  motions  of  the  tumours  on  the  forehead  and  cheek  en- 
tirely ceased  :  but  a  slight  thrilling  w^s  still  perceptible  in  the  tumid 
upper  eyelid.  The  red  sw'elling  of  the  lower  eyelid  became  paler, 
and  its  surface  shrivelled.  A  few  minutes  after  the  patient  wa; 
placed  in  bed,  she  was  quite  free  from  pain,  and  the  noise  by  which 
she  had  been  so  long  tormented  having  also  ceased,  she  declared 
that  her  head  no  longer  felt  like  her  old  head.  At  .5,  p.  m.  there 
was  no  pulsation  in  any  of  the  tumours.  Next  day  the  upper  eye- 
lid, for  the  first  time  during  several  months,  was  movable.  The 
day  after,  the  tumour  over  the  inner  part  of  the  eyebrow  was  entirely 
gone  ;  the  swelling  of  the  upper  eyelid  was  much  smaller,  its  tex- 
ture much  softer,  and  it  was  less  painful  when  compressed ;  the 
globe  of  the  eye  also  had  considerably  retired  within  its  orbit.  By 
the  Loth  of  April,  great  changes  had  taken  place  in  the  tumours;'' 
the  globe  of  the  eye  had  completely  retired  within  its  orbit,  the  gen- 
eral prominence  of  the  upper  eyelid  had  sunk  proportion  ably,  and 


247 

■  not  the  slightest  pulsatory  orthrilhng  motion  was  perceptible  in  any 
of  the  diseased  parts.  By  the  17th  of  May,  the  tiimouis  had  all 
'disappeared,  and  the  patient's  general  health  seemed  re-established  ; 
iyet  the  wound  was  not  entirely  closed,  although  the  ligatures  had 
iconie  away,  the  upper  on  the  l8lh  of  April,  and  the  lower  on  the 
4th  of  May.  On  the  evening  of  the  3d  of  July,  Mr.  D.  was  called 
in  great  haste,  in  consequence  of  a  bleeding  which  had  taken  place 
at  the  lower  part  of  the  wound.  The  haemorrhage  had  ceased  be- 
fore he  could  reach  the  house.  The  colour  of  the  blood  was  florid, 
land  the  quantity  lost  10  or  12  ounces.  A  similar  discharge  took 
iplace  on  the  evening  of  the  9th  of  July,  but,  like  the  former,  ceased 
spontaneously,  and  happily  proved  the  last  of  a  series  of  incidents, 
not  unlikely  to  disappoint  the  hopes  which  the  earlier  circumstances 
lof  the  case  had  inspired.  From  this  period  the  course  of  events  was 
prosperous ;  and  on  the  19th  of  July,  which,  reckoning  from  the 
iiTiorning  of  the  operation,  comprises  a  period  of  103  days,  the  wound 
swas  firmly  healed,  and  the  patient's  recovery  secured.  After  a  lapse 
of  nearly  two  years,  her  cure  appeared  complete,  with  the  exception 
I  of  her  sight,  which  seemed  irrecoverably  lost.  With  respect  to  the 
state  of  the  local  circulation,  there  was  no  pulsation  to  be  felt  in  any 
:of  the  branches  of  the  left  temporal  and  facial  arteries ;  but,  as  in  the 
icase  treated  by  Mr.  Travers,  the  carotid  might  be  distinguished 
I  beating  very  feebly  below  the  angle  of  the  jaw,  while  a  very  brisk 
action  of  the  collateral  branches  lying  near  the  surface,  was  visible 
in  the  vicinity  and  along  the  course  of  the  cicatrice.* 

2.  Aneurism  of  the   Ophthalmic  Artery. 
\     liike  the  internal  carotid  by  the  side  of  the  sella  turcica,  the  an- 
terior cerebral,  and  other  arteries  within  the  cranium,  the  ophthal- 
mic  artery  within  the  orbit  is  subject  to   true  aneurism.      Mr. 
j  Guthrie  states,  that  he  saw  a  case  of  this  kind,  in   which   both 
[ophthalmic    arteries  were  dilated,  and  which   terminated  fatally. 
iThe  symptoms  were  similar  to  those  of  aneurism  by  anastomosis, 
;but  no  tumour  could  be  perceived.     The  eye  was  gradually  pro- 
(truded  until  it  seemed  to  be  exterior  to  the  orbit,  but   vision  was 
:  scarcely  aflfected.     The  hissing  noise  in  the  head  could  be  distinctly 
;  heard,  and  was  attributed  to  aneurism.     On  the  death  of  the  pa- 
tient, an  aneurism  of  the  ophthalmic  artery  was  discovered  on  each 
side,  of  about  the  size  of  a  large  nut.     The  ophthalmic  vein  was 
greatly  enlarged,  and  obstructed  near  where  it  passes  through  the 
sphenoid  fissure,  in  consequence  of  a  great  increase  of  size  which 
the  four  recti  muscles  had  attained,  accompanied  by  an  almost  car- 
,  tilaginous  hardness,  which  had  been  as  much  concerned  in  the 
protrusion  of  the  eye  as  the  enlargement  of  the  vessels.     The  di- 
sease existing  on  both  sides  prevented  Mr.  G.  from  proposing  any 
operation  on  the  carotid,  to  which  indeed,  he  thinks,  the  patient 
would  not  have  submitted.! 

*  Medico-Chirurgical  Transactions,  Vol.  vi.  p.  111.     London,  1815. 

t  Lectures  on  the  Operative  Surgery  of  the  Eye,  p.  158.    London,  1823. 


248 

CHAPTER  IX. 

INJURIES  OF  THE  EYEBALL. 


In  the  first  section  of  Chapter  lY.,  we  have  considered  the  injurii 
of  the  muco-cutaneous  membrane,  which  covers  the  anterior  third! 
of  the  eyeball.     We  have  now  to  turn  our  attention  to  the  injuries 
which  affect  its  proper  textures.  ^ 


SECTION  I — INJURIES  OF  THE  CORNEA. 

1.  Contusion  of  the  Cornea. 

Foreign  bodies,  of  small  bulk,  impinging  with  violence  against 
the  cornea,  and  immediately  flying  off,  are  sometimes  followed  by 
very  severe  inflammation,  ending  in  ulceration  of  the  part  struck, 
infiltration  of  matter  between  the  lamellee  of  the  cornea,  and  other  i 
dangerous  effects. 

2.  Foreign  Substances  adhering  to  the  Cornea. 

Foreign  particles  frequently  adhere  to  the  surface  of  the  cornea,  i 
The  irritation  created  is  generally  so  considerable,  that  the  patient  \ 
is  led  to  make  immediate  application  for  rehef :  and  if  the  foreign 
body  has  not  become  imbedded  in  the  substance  of  the  cornea,  in 
consequence  of  the  patient's  rubbing  the  eye,  and  forcibly  winking 
and  shutting  the  eyelids,  the  removal  of  the  cause  of  irritation  is 
easily  effected,  with  the  point  of  a  picktooth.  It  sometimes  hap- 
pens, however,  that  the  irritation  does  not  attract  suflicient  attention, 
so  that  the  foreign  substance  is  left  for  days  or  even  weeks,  bring- 
ing on  inflammation  or  even  ulceration,  without  any  attempt  being 
made  to  discover  the  cause  or  to  remove  it.  Morgagni  relates  a 
case  where  an  insect  having  darted  into  the  eye,  one  of  its  wings 
was  left  sticking  to  the  cornea,  where  it  created  an  ulcer,  which 
immediately  got  well  when  the  wing  was  removed.  The  foreign 
bodv,  adhering  to  the  cornea,  may  even  be  mistaken  for  the  pro- 
duct of  disease,  and  no  direct  attempt  made  to  remove  it  in  conse- 
quence of  this  mistake.  Thus.  Wenzel  relates  a  case  where  the 
husk  of  a  seed  adhered  for  four  months  to  the  cornea  of  a  child. 
A  round  yellowish  spot  was  perceived  on  the  cornea,  elevated 
above  its  surface,  and  which  from  its  resemblance  to  a  pustule  had 
been  treated  as  such.  From  this  spot  proceeded  a  number  of  vari- 
cose vessels  diverging  like  radii  from  a  centre.  It  turned  out  to 
be  the  hard  skin  of  a  millet  seed,  which  had  stuck  on  the  cornea 
in  such  a  manner  that  its  sharp  edge  and  concave  side  adhered, 
whilst  its  smooth  convex  surface  formed  an  elevation  like  a  minute 
pustule. 

3.  Foreign  Substances  im^bedded  in  the  Cornea. 

It  is  a  very  common  occurrence  for  minute,  hard,  angular,  and 
sometimes  ignited  particles  to  be  projected  with  such  force,  as  to 


249 

penetrate  at  once  into  the  substance  of  the  cornea ;  for  instance,  a 
spark  from  the  anvil,  a  minute  fragment  of  stone,  or  a  particle  of 
glass.     The  presence  of  even  a  very  small  body  of  this  description, 
so  small,  indeed,  that  it  may  be  with  difficulty  that  we  are  able  to 
detect  it,  produces  a  constant  flow  of  tears,  spasm  of  the  orbicularis 
palpebrarum,  and  speedy  inflammation  of  the  external  tunics  of 
the  eye.     These  symptoms  do  not,  in  general,  subside  until  the 
foreign  substance  is  either  removed  by  art,  or  comes  away  by  a 
tedious  and  painful  process  of  suppuration.     In  a  few  hours  after 
the  extraneous  substance  becomes  imbedded  in  the  cornea,  its  ad- 
jacent portion  becomes  opaque,  and  the  opacity  extends  according 
to  the  violence  of  the  inflammatory  symptoms  which    succeed. 
The  conjunctiva  and  sclerotica  become  more  or  less  vascular,  and 
the  pain  is  varied  in  kind,   and  more  or  less  severe,   according  as 
the  one  or  the  other  of  these  tunics  is  chiefly  affected  with  inflam- 
mation.    If  the  conjunctiva  is  the  chief  seat  of  the  increased  vas- 
3ularity,  the  eye  feels  rough,  and  as  if  filled  with  sand  ;  if  there  is 
considerable   sclerotitis,   nocturnal  circum-orbital    pain    is   excited, 
[ritis  may  even  be  brought  on,  if  the  case  continues  to  be  neglected, 
ending  in  effusion  into  the  pupil.     In  the  meantime,  the  part  in 
contact  with   the  foreign   particle,   killed  perhaps  by  the  impetus 
vvith  which  it  was  struck,  or  scarred  by  the   ignited  state  of  the 
mrticle,  is  gradually  reduced  to  the  state  of  a  slough,  and  loosened 
Dy  the  processes  of  ulceration  and  suppuration,  so  that  at  length, 
1 1  drops  out  along  with  the  foreign  substance,  and  leaves  an  ulcer 
)f  the  cornea,   more  or  less  deep,  and  often  of  a  brownish  colour, 
vhich  in  general  heals  up  readily,  leaving  a  cicatrice  or  leucoma. 
Occasionally  it  happens  that  the  inflammation  of  the  cornea  is  very 
;evere,  and  gives  rise  to  infiltration  of  matter  between  its  lamellae. 
■  I  the  foreign  body  is  removed,  and  the  inflammation  abated  by 
antiphlogistic  means,  the  matter  is  absorbed ;  but  if  the  case  is  still 
[leglected,  the  purulent  effusion  may  increase,  hypopium   may  be 
lidded  to  the  onyx  which  already  exists,  and   the  eye  will,  in  all 
'  )robability,  be  entirely  destroyed.     This  result  is  particularly  apt 
0  follow,  when  rude  attempts  are  made  by  common  work-people, 
0  remove  particles  of  wliinstone  and  iron,  which  have  become  fixed 
n  the  cornea.     I  could  quote  several  lamentable  cases  of  this  sort 
"roiTi  the  journals  of  the  Eye  Infirmary,  in  which  a  conceited  me- 
:hanic,  with  a  common  penknife,    having  in  various  instances 
ittempted  the  removal  of  a  Jire  or  ignited  particle  of  iron,  fixed  in 
he  cornea,   violent  inflammation    followed,  ending  in    extensive 
ilceration,  onyx,  hypopium,  staphyloma,  and  of  course  entire  loss 
if  vision. 

It  is  sometimes  the  case,  after  a  foreign  body  has  lain  imbedded 

3r  a  time  in  the  cornea,   that  a  layer  of  new  substance  is  formed 

iver  it,  so  that  the  inflammation  at  first  excited  by  its  presence 

eases,  and  it  remains  through  life  without  giving  rise  to  any 

32 


250 

farther  irritation.  We  see  this  frequently  happen  to  grains  of  gun- 
powder. 

In  other  cases,  the  shape  of  the  foreign  substance,  or  the  manner 
in  which  it  is  fixed  in  the  cornea,  may  prevent  it  from  either  drop- 
ping out,  or  becoming  invested  in  the  manner  now  mentioned ;  it 
will  continue,  therefore,  to  produce  irritation  and  inflammation, 
which  may  prove  destructive  to  vision.  I  shall  have  occasion, 
under  the  head  of  penetrating  wounds  of  the  cornea,  to  quote  a 
case  which  occurred  in  Mr.  Wardrop's  practice,  which  will  illustrate 
this  point. 

The  best  instrument  for  removing  foreign  particles  fixed  on  the 
surface  of  the  cornea,  or  slightly  imbedded  in  its  substance,  is  a 
straight  cataract  needle.  The  edge  of  the  instrument  near  its 
point,  rather  than  the  point  itself,  is  to  be  used  for  dislodging  the 
offending  body.  This  is  not  accomplished  in  many  cases,  without 
fairly  pressing  the  edge  of  the  needle  under  the  particle  of  iron  or 
stone,  so  as  to  dig  or  lift  it  out  of  the  cornea.  This  cannot  be  done 
so  safely  \vith  the  point  of  the  needle ;  for  should  we  attempt  it 
with  the  point,  we  may  readily  enough  miscalculate  the  force  we 
employ,  so  that  the  needle  passes  through  the  cornea  into  the 
anterior  chamber.  An  assistant,  standing  behind  the  patient,  must 
support  the  head,  raise  the  upper  eyelid,  and  prevent  the  eyeball 
from  rolling  upwards,  when  we  proceed  to  the  operation.  If  no 
assistant  be  at  hand,  we  fix  the  head  of  the  patient  against  the 
wall,  and  separate  the  lids  with  the  fingers  of  the  hand  which  does 
not  hold  the  needle.  When  the  extraneous  body  is  removed  by 
art,  it  leaves  a  depression  in  the  cornea,  which  in  general  is  soon 
filled  up ;  and  the  surrounding  opacity  is  gradually  removed.  It 
is  often  the  case  that  a  considerable  portion  of  its  conjunctival  cov- 
ering is  abraded,  in  removing  foreign  particles  fixed  in  the  cornea, 
but  that  covering  is  reproduced  perfectly  transparent,  unless  acetate 
of  lead  is  afterwards  used  in  solution,  as  it  often  unfortunately  is, 
for  bathing  the  eye.  This  application  renders  the  cicatrice  opaque. 
Nitras  argenti  and  murias  hydrargyri  in  solution  have  not  the 
same  effect.  The  former  is  often  useful,  in  such  cases,  in  pro- 
moting cicatrization  ;  but,  in  general,  a  little  warm  milk  and  water 
will  serve  as  a  sufficient  collyrium,  employed  three  or  four  times  a 
day.  If  the  spasm  of  the  orbicularis  palpebrarum  does  not  speedily 
subside  after  the  removal  of  the  foreign  particle,  a  warm  poultice 
made  with  decoction  of  poppy-heads,  and  enclosed  in  a  linen  bag 
may  be  laid  over  the  eye.  Bleeding  with  leeches,  or  from  a  vein 
of  the  arm,  is  highly  beneficial,  and  must  on  no  account  be  neglect- 
ed when  much  iiTitation  has  been  produced ;  the  patient  should 
be  purged,  and  should  remain  at  rest,  without  attempting  to  use 
the  eyes,  till  all  danger  of  inflammation  is  past. 

Although  it  generally  happens  that  when  the  cornea  heals  over 
any  minute  fragment  of  foreign  matter  imbedded  in  its  substance, 
all  irritation  ceases  ;  yet  this  is  not  always  the  case.     I  remember 


251 

Dr.  C,  Jaeger  presenting  a  case  for  consultation  at  Professor  Beer's 
house,  of  a  foreign  body  which  had  remained  for  five  years  in  the 
cornea.  It  was  said  to  be  a  spicula  of  glass.  The  lower  half  of 
the  cornea  was  somewhat  opaque,  the  opacity  was  gradually  in- 
creasing, and  the  eye  was  affected  with  frequent  stinging  pain. 
The  foreign  substance  was  of  a  pyramidal  form,  very  slender, 
stretching  from  the  lower  edge  towards  the  centre  of  the  cornea, 
and  partly  from  its  own  transparency,  partly  from  the  haziness  of 
the  cornea,  it  was  perceived  with  difficulty  even  on  close  examina- 
tion. From  the  consideration  that  the  woman  was  daily  losing  her 
sight  more  and  more  from  the  increasing  opacity  of  the  cornea,  it 
was  agreed  that  an  attempt  should  be  made  to  extract  the  piece  of 
glass,  and  a  discussion  took  place,  whether  the  instrument  with 
which  the  incision  was  to  be  made  should  be  carried  before  or  be- 
hind the  body  to  be  extracted.  With  the  cataract  knife,  Dr.  C.  J. 
made  an  incision  through  the  lower  part  of  the  cornea.  Unfortu- 
nately, however,  he  happened  to  touch  the  sclerotica  before  enter- 
ing the  knife  into  the  cornea,  so  that  the  eyeball  was  covered  with 
blood  from  the  conjunctiva,  and  further,  the  patient  turned  her  eye 
forcibly  upwards  and  inwards,  so  that  the  incision  was,  in  a  con- 
siderable degree,  made  in  the  dark.  As  soon  as  the  incision  was 
completed,  the  patient  became  faint,  and  it  was  not  till  after  the 
faintness  went  off,  that  the  foreign  substance  could  be  sought  for. 
I  heard  it  distinctly  touched  by  Daviel's  spoon.  A  pair  of  for- 
ceps was  then  employed  for  its  removal ;  but  neither  with  the  for- 
ceps, nor  with  a  delicate  probe,  could  it  again  be  felt.  It  had  prob- 
ably given  way,  from  its  extreme  tenuity,  on  being  touched  with 
Daviel's  spoon.  Some  particles  of  it  might  have  been  washed 
away  by  the  blood  and  aqueous  humour,  while  others  might  have 
slipped  behind  the  wound  into  the  anterior  chamber.  The  wound 
healed  readily,  and  the  pain  which  had  been  felt  previous  to  the 
operation  was  relieved.  I  am  unable  to  state  any  thing  regarding 
the  effects  of  the  operation  on  the  opacity  of  the  cornea. 

4.  Punctured  Wounds  of  the  Cornea 

Are  apt  to  be  followed  by  violent  inflammation,  and,  what  is  very 
remarkable,  by  a  dragging  of  the  pupil  towards  the  puncture,  even 
when  the  wound  has  not  passed  through  the  whole  thickness  of  the 
cornea,  so  as  to  reach  the  anterior  chamber.  Of  the  latter  effect, 
Demours  has  narrated  and  figured  an  instance.  The  cornea  is 
represented  as  nebulous  round  the  point  which  had  been  touched 
by  the  instrument  of  injury,  and  the  pupil  drawn  up  into  an  acute 
angle  opposite  to  the  seat  of  the  puncture.* 

Cases  of  punctured  wounds  of  the  cornea  must  be  watched  with 
great  care,  as  the  inflammation  which  follows  is  sometimes  rapidly 
destructive.     I  have  seen  a  prick  with  a  needle  produce,  in  the 

*  Traite  des  Maladies  des  Yeux.    Planche  52.     Fig.  3.    Paris,  1818. 


252 

course  of  a  few  days,  during  which  the  case  was  neglected,  such  a 
degree  of  infianiraction,  as  ended  in  a  copious  deposition  of  lymph 
and  pus  between  the  lamellae  of  the  cornea,  and  in  the  anterioi 
chamber.  The  liberal  application  of  leeches,  bleeding  at  the  ami; 
purgatives,  the  use  of  belladonna  so  as  to  oppose  closure  of  the  pu- 
pil, rest,  and  a  strict  antiphlogistic  regimen,  will  be  required,  along 
"with  the  use  of  calomel  and  opium,  blisters,  &c.  The  calomel 
and  opium,  and  the  belladonna,  are  directed  against  the  inflamma- 
tion of  the  iris,  which  is  apt  to  arise,  and  end,  if  neglected,  in  closure 
of  the  pupil. 

5.  Penetrating   Woimds  of  the  Cornea — Loss  of  the  Aqueous 
Humour — Prolapsus  of  tho-  Iris. 

As  the  wounds  which  penetrate  through  the  cornea  into  the  an- 
terior chamber  var}-  much  in  their  nature,  being  either  clean-incised 
or  lacei-ated. — in  their  extent,  from  a  mere  puncture  to  the  whole  t 
breadth  of  the  cornea. — and  in  their  situation,  being  sometimes  at 
the  edge,  and  in  other  cases  near  the  centre  of  the  cornea, — so  their 
effects  are  very  different  in  different  instances.  AVe  meet  with 
penetrating  wounds  of  the  cornea,  so  small  and  so  obhque,  that 
they  give  rise  to  no  discharge  of  aqueous  humour,  and  heal  by 
the  first  intention,  leaving  scarcely  any  visible  cicatrice ;  in  some 
cases,  the  wound,  for  weeks,  permits  the  aqueous  humour  to  ooze 
through  it.  but  at  length  unites,  and  perhaps  leaves  the  eye  with- 
out any  serious  permanent  defect ;  while  in  others,  the  wound  in- 
flames, suppurates,  and  leaves  an  opaque  unseemlj^  cicatrice,  which 
interferes  more  or  less  with  vision,  according  to  its  situation,  rela- 
tion to  the  pupil,  and  extent.  In  nine  cases  out  of  ten,  penetrating 
wounds  of  the  cornea  are  followed  by  the  instantaneous  escape  of 
a  considerable  portion  of  aqueous  humour,  and  a  protrusion  of  the 
iris.  The  latter  consequence  is  much  more  apt  to  occur  if  the 
opening  in  the  cornea  is  situated  near  its  edge.  It  results  partly 
from  the  iris  losing  the  support  of  the  aqueous  humour  which  has 
been  evacuated,  partly  from  the  push  made  by  the  rest  of  that  fluid 
to  escape  also  by  the  wound.  The  pupil  is  dragged  towards  the 
prolapsed  portion  of  iris,  and,  as  but  too  often  the  prolapsus  remains 
unreduced,  the  iris  unites  to  the  hps  of  the  wound,  and  the  defor- 
mity is  permanent. 

The  loss  of  the  aqueous  humour,  although  regarded  by  the  an- 
cients as  equivalent  to  the  loss  of  vision,  is  speedily  repaired  b}"  the 
re-secretion  of  that  fluid.  The  replacement  of  the  prolapsed  iris  is 
a  matter  of  much  greater  difficulty.  It  is  often  impossible  to  effect 
this  replacement :  indeed,  Mr.  Lawrence  states  he  has  never  seen 
it  accomphshed.*  We  may,  however,  occasionally  succeed,  by  the 
following  means,  if  they  be  employed  within  an  hour  or  two  after 
the  accident,  and  especially  if  it  is  the  pupillary  portion  of  the  iris 


Lectures  in  the  Lancet,  Vol.  X.  p.  482.    London,  1826. 


i 


253 

which  is  prolapsed.     We  find  the  eye  ah-eady  inflamed,  intolerant 
!  of  light,  and  probably  acutely  painful.     The  cornea  will,  in  general, 
i  be  more  or  less  flaccid,  and,  on  attempting  to  fix  the  eye,  there  is 
I  apt  to  follow  a  farther  discharge  of  aqueous  humour.     The  first 
(  means  to  be  had  recourse  to  is  gentle  friction  of  the  eye  through 
the  eyelid,  continued  for  the  space  of  about  half  a  minute,  and  then 
,  sudden  exposure  of  the  eye  to  a  bright  light.     If  this  does  not  suc- 
ceed, we  may  endeavour,  with  a  small  blunt  probe,  to  lift  one  edge 
!  of  the  wound,  and  push  the  iris  into  the  anterior  chamber ;  and 
I  then,  whether  we  succeed  or  not  with  the  probe,  repeat  the  friction 
I  of  the  eye  and  the  exposure  to  bright  light.     If  we  still  fail  in  ac- 
jicomphshing  the  reduction,  and  if  the  wound  is  so  situated  between 
I  the  centre  and  the  edge  of  the  cornea,  that  it  is  the  pupillary  por- 
tion of  the  iris  which  is  prolapsed,  we  may  next  have  recourse  to 
[belladonna,  smearing  the  extract  on  the  eyebrows  and  lids,  and 
idropping  a  filtered  solution  of  it  upon  the  eyeball.     In  the  course 
of  from  fifteen  to  thirty  minutes,  the  influence  of  the  belladonna 
will  have  probably  operated  on  the  unprolapsed  portion  of  the  iris, 
so  as  to  dilate  the  pupil,  and  perhaps  to  drag  back  into  its  natural 
place  the  prolapsed  portion.     But  if  the  wound  is  close  to  the  edge 
of  the  cornea,   belladonna  ought  not  to  be  employed,  as  it  only 
tends,    in    this    case,    to  produce  a  greater  degree  of  prolapsus. 
After  the  belladonna  has  been  applied  a  sufficient  length  of  time, 
our  attempts  by  friction,  and  with  the  probe,  are  to  be  renewed.     If 
we  are  successful,  some  recommend  the  wound  to  be  freely  touched 
with  a  sharp  pencil  of  lunar  caustic,  so  as  to  form  a  minute  slough, 
which  may  act  as  a  plug,  and  prevent  any  farther  discharge  of  the 
aqueous  humour. 

Should  all  our  attempts  to  reduce  the  prolapsed  portion  of  iris 
fail,  we  have  still  a  choice  left  of  snipping  it  off  with  the  scissors, 
or  of  leaving  it  slowly  to  contract,  and  disappear.  The  former  is 
certainly  the  preferable  practice  ;  for  if  left  to  itself,  it  long  proves 
the  cause  of  irritation,  and  leaves  a  broader  cicatrice  than  if  it  had 
been  removed.  If  the  patient  refuses  to  permit  this  to  be  done,  the 
prolapsed  portion  may  be  touched  every  second  day  with  nitras  ar- 
genti.  Under  this  treatment,  it  gradually  shrinks,  becomes  covered 
with  a  lymphatic  effusion,  and  at  length  disappears,  the  pupil  being 
left  permanently  disfigured,  and  vision  more  or  less  abridged  ac- 
cording to  the  size  and  situation  of  the  cicatrice. 

The  penetrating  wounds  of  the  cornea  of  which  we  have  been 
speaking  are  those  effected  by  foreign  substances  which  are  imme- 
diately withdrawn,  as  the  point  of  a  penknife,  fork,  or  pair  of  scis- 
sors, sharp  pieces  of  wire  or  wood,  splinters  of  metal  or  stone  pro- 
jected against  the  eye,  and  the  like.  It  sometimes  happens,  how- 
ever, that  the  body  with  which  the  injury  is  inflicted,  is  left  sticking 
in  the  cornea.  The  following  is  the  instance  of  this  sort  to  which 
I  have  referred  at  page  250.  A  patient  applied  at  Mr.  Wardrop's 
hospital,  under  the  following  circumstances.    On  the  temporal  edge 


254 

of  the  left  cornea  there  was  an  opaque  spot ;  the  pupil  was  irregular, 
and  adhered  to  the  opaque  spot  of  the  cornea  ;  and  there  was  coi> 
siderable  redness  of  the  white  of  the  eye,  and  great  intolerance  oi 
light.  Fourteen  weeks  before,  when  twisting  a  piece  of  gold  wire, 
a  small  portion  of  it  broke  off  and  struck  the  eye.  Three  days 
after  the  accident,  intense  inflammation  came  on,  with  severe  pain, 
which  continued  for  five  weeks,  and  resisted  active  depletion.  From: 
this  period,  the  pain  became  less  acute.  A  few  days  after  applying 
at  the  hospital,  a  portion  of  gold  wire  v;as  observed  projecting  be- 
yond the  surface  of  the  cornea,  and  a  considerable  portion  seemed 
to  be  impacted  in  the  opaque  spot.  It  was  easily  extracted  by 
means  of  a  pair  of  forceps,  and  was  followed  by  a  discharge  of  the 
aqueous  humour.  The  portion  of  wire  was  fully  three  lines  in 
length,  and  one  extremity  had  penetrated  into  the  anterior  chamber. 
The  patient  felt  much  relieved  immediately  after  the  extraction  of 
the  foreign  substance,  and  the  inflammation  and  opacity  soon  sub- 
sided.* 

In  many  instances  of  penetrating  wound  of  the  cornea,  the  for- 
eign body  enters  completely  into  the  anterior  chamber,  and  there 
remains  till  we  extract  it.  We  sometimes  find  that  it  has  fallen  to 
the  bottom  of  the  anterior  chamber,  more  frequently  that  it  is  fixed 
in  the  iris  or  in  the  lens,  rarely  that  it  has  passed  behind  the  iris  so 
as  to  lie  in  the  posterior  chamber.  In  all  these  cases  we  proceed 
immediately  to  its  removal,  unless  it  be  of  a  very  small  size.  A 
grain  of  gunpowder,  for  example,  which,  passing  through  the  cor- 
nea, is  fixed  on  the  anterior  surface  of  the  iris,  or  perhaps  even  a 
particle  of  metal  of  the  same  size,  we  should  allow  to  remain.  It 
has  repeatedly  happened  that  the  point  of  a  cataract  knife  or  needle, 
breaking  off  in  the  anterior  chamber,  has  been  left  there,  and  has 
become  oxidized  and  dissolved.!  Larger  and  rougher  metaUic  frag- 
ments we  cannot  calculate  on  being  removed  in  this  manner.  If 
they  are  fixed  in  the  iris,  or  if  they  are  impacted  between  the  cornea 
and  the  iris,  although  without  any  laceration  of  the  latter,  they 
will  almost  certainly  bring  on  iritis ;  and  even  if  merely  in  contact 
with  the  chrystalline  capsule,  without  this  part  being  divided,  cata- 
ract is  the  invariable  result.  Remove  a  metallic  fragment  from 
these  several  situations,  and  iritis  and  cataract  may  be  prevented. 
In  doing  this,  however,  there  is  a  danger  of  wounding  the  iris,  of 
touching  the  capsule  so  as  to  admit  the  aqueous  humour  into  con- 
tact with  the  lens,  which  will  cause  cataract,  and  of  the  iris  pro- 
lapsing after  the  foreign  body  is  removed. 

The  extraction  of  a  foreign  body  from  the  anterior  chamber  may 
sometimes  be  accomplished  by  means  of  a  small  pair  of  forceps, 
introduced  through  the  wound  of  the  cornea  already  present ;  but 
in  other  cases,  this  cannot  be  done,  and  the  cornea  must  be  opened 

-*  Lancet,  Vol.  x.  p.  475.     London,  1826. 

t  Lawrence's  Lectures  in  the  Lancet.     Vol.  ix.  p.  53L    London,  1826. 


265 

with  the  cataract  knife,  about  the  tenth  of  an  inch  from  the  edge 
of  the  sclerotica.  If  the  incision  be  made  closer  to  the  sclerotica 
than  this,  protrusion  of  the  iris  is  very  likely  to  occur,  and  will  in 
general  be  found  irreducible.  I  have  seen  the  application  of  bella- 
donna, in  a  case  in  which  an  angular  fragment  of  steel  was  im- 
pacted between  the  iris  and  the  cornea,  dilate  the  pupil  and  carry 
the  foreign  body  along  with  the  iris  to  the  very  edge  of  the  cornea; 
but  I  do  not  consider  this  as  a  practice  to  be  followed  preparatory 
to  extracting  the  foreign  substance  by  an  incision  of  the  cornea,  as, 
I  think,  it  favours  prolapsus  of  the  iris.  Not  unfrequently  it  hap- 
pens that  as  soon  as  the  incision  is  made  through  the  cornea,  the 
foreign  body  rushes  out  along  with  the  aqueous  humour,  so  that 
we  are  saved  from  any  trouble  of  extracting  it  with  forceps. 

6.    Burns  of  the  Cornea. 

I  have  seen  several  cases  in  which  the  cornea  being  touched 
with  hot  pieces  of  metal,  its  conjunctival  covering  w^as  raised  like  a 
iblister,  and  considerable  fear  entertained  lest  vision  should  be  lost. 
The  conjunctiva,  however,  has  been  regenerated  perfectly  transpa- 
rent in  some  of  these  cases,  and  in  others  with  only  a  slight  degree 
! of  obscurity. 

It  has  been  very  different  with  injuries  of  the  cornea  from  sul- 
phuric acid  and  from  quicklime.  Deep  ulceration  of  the  cornea, 
with  hypopium,  and  total  opacity  of  the  front  of  the  eye,  have  fol- 
lowed in  such  cases. 


SECTION    II, INJURIES  OF  THE  IRIS. 

These  are,  in  the  first  place,  punctures  and  lacerations  through 
the  cornea ;  in  the  second,  displacement ;  and  thirdly,  separation 
of  the  ciliary  edge  of  the  iris  from  the  choroid. 

Punctures  and  lacerations  of  the  iris  are  apt  to  be  followed  by 
dilatation  of  the  aperture,  so  as  to  form  a  false  pupil.  Inflamma- 
tion is  to  be  guarded  against  in  such  cases,  and  combated  by  the 
means  hereafter  to  be  recommended  for  iritis. 

Blows  on  the  eye,  (for  instance,  with  the  fist,)  are  not  unfre- 

'quently  followed  by  displacement  of  a  considerable  portion  of  the 

iris.     The  pupil  is  greatly  enlarged,  and  one-half,  perhaps,  of  the 

iris  is  thrust  out  of  sight,  so  that  the  pupil  extends  on  one  side  to 

the  very  edge  of  the  cornea.    This  accident  is  generally  attended  by 

effusion  of  blood  into  the  eye,  and  by  amaurosis. 

1     The  connexion  between  the   iris  and  the  choroid  is  much  less 

<;firm  in  man  than  in  quadrupeds,  and  the  consequence  is  that 

'smart  blows  on  the  human  eye  are  apt  to  separate  the  one  of  these 

j  membranes  from  the  other,  so  as  to  form  a  false  pupil  exterior  to 

the  circumference  of  the  iris.     The  stroke  of  a  whip,  a  horse's 

tail,  or  the  twig  of  a  tree  is  frequently  the  cause  of  this  accident. 


256 

We  have  no  means  of  bringing  back  the  iris  to  its  former  situation.!^ 
Belladonna  dilates  the  false  pupil  as  well  as  the  natural  one,  nar- 
rowing the  portion  of  iris  between  them.     The  vision  of  the  eye  is, 
in  general,  much  debihtated  after  this  sort  of  accident.  ! 


SECTION  III. INJURIES  OF  THE  CHRYSTALLINE  LENS  AND 

CAPSULE. 

Punctures  of  the  capsule,  by  means  of  pointed  or  cutting  instru- 
ments pushed  through  the  cornea,  are  followed  by  the  admission  of 
the  aqueous  humour  into  contact  with  the  lens,  which  produces 
opacity  or  cataract.  The  edges  of  the  puncture  or  wound  of  the 
capsule  are  apt  to  inflame  and  become  of  a  chalky  white  colour. 
If  they  unite,  so  that  the  aqueous  humour  is  no  longer  admitted 
into  contact  with  the  lens,  the  progress  of  the  cataract  will  be  ar- 
rested. If  the  wound  of  the  capsule  is  considerable  and  does  not 
heal,  the  whole  lens  becomes  coagulated  and  opaque,  and  in  a  young 
or  middle-aged  person  is  gradually  dissolved,  so  that  the  pupil  clears 
and  a  certain  degree  of  vision  is  recovered. 

Blows  on  the  eye  sometimes  rupture  the  capsule,  so  that  the  lens 
escapes.  "When  this  is  the  case,  the  lens  generally  passes  forward 
through  the  pupil,  and  lodges  in  the  anterior  chamber,  causing 
great  pain  and  irritation,  and  bringing  on  inflammation.  When 
this  happens,  the  cornea  is  to  be  opened,  as  in  common  extraction 
of  the  cataract,  taking  care,  however,  to  pass  the  knife  behind  the 
dislocated  lens,  especially  if  some  weeks  or  months  have  elapsed 
since  the  accident.  The  use  of  this  direction  is  to  prevent,  if  pos- 
sible, the  lens  from  slipping  back  through  the  pupil,  and  sinking 
into  the  vitreous  humour,  which,  in  consequence  of  the  injury 
which  it  has  sustained,  in  injuries  of  this  sort,  we  generally  find 
in  a  dissolved  state.  The  retina  is  also  rendered  almost  always  in- 
sensible by  the  blow  which  produces  the  dislocation  of  the  lens. 
In  some  neglected  cases  of  this  accident,  I  have  known  the  opaque 
lens  lie  for  years  in  the  posterior  chamber,  where  it  was  seen 
bobbing  about,  on  every  movement  of  the  eye  or  head,  but  occa- 
sionally passing  through  the  pupil  into  the  anterior  chamber,  and 
returning  again  into  the  posterior,  till  on  some  particular  occasion 
more  irritation  being  excited  by  its  presence  in  the  anterior  cham- 
ber than  usual,  iritis  has  come  on  with  great  pain  in  the  eye  and 
head,  contraction  of  the  pupil,  and  an  impossibility  of  getting  the 
lens  to  retire,  as  it  had  been  wont  to  do,  into  the  posterior  chamber. 
Under  these  circumstances,  however  unfavourable  for  an  operation, 
the  extraction  of  the  dislocated  lens  must  be  resorted  to,  that  the 
patient  may  be  freed  from  the  severe  pain  attending  the  iritis,  and 
the  sound  eye  saved  from  the  danger  of  sympathetic  inflammation. 

Another  accident  to  which  the  lens  and  its  capsule  are  subject  in  ' 
consequence  of  blows  on  the  eye,  is  separation  of  both  from  the 


257 

vitreous  humour,  so  that  the  capsule,  enclosing  the  lens,  becomes 
entirely  insulated.  In  this  case,  the  capsule  thickens,  the  lens  co- 
agulates and  dissolves,  and  the  cataracta  cystica  which  is  thus 
formed  moves  in  the  posterior  chamber,  and  occasionally  comes 
forward,  like  the  lens  in  the  former  case,  into  the  anterior  chamber. 
If  we  extract  this  kind  of  cataract,  we  do  so  not  to  restore  vision, 
for  the  eye  is  uniformly  amaurotic,  but  to  save  the  patient  from 
pain. 


SECTION    IV. WOUNDS    OP   THE    SCLEROTICA    AND    CHOROIDEA. 

Incised  wounds  of  the  conjunctiva  and  sclerotica,  are  instantly 
followed  by  a  protrusion  of  the  choroidea,  which  we  have  no  other 
means  of  repressing,  than  by  directing  the  patient  to  keep  the  eye- 
lids as  much  shut  as  possible,  so  as  to  give  a  degree  of  support  to 
the  eyeball,  till  the  wound  heals.  This  it  never  does  without 
leaving  a  considerable  cicatrice,  the  space  between  the  edges  of  the 
wounded  sclerotica  being  filled  up  by  an  effusion  of  lymph  which 
gradually  assumes  the  appearance  and  texture  of  a  membrane. 
The  conjunctiva  sometimes  heals  in  cases  of  this  kind,  while  the 
sclerotica  continues  open,  with  the  choroidea  projecting  through  it. 

Where  both  sclerotica  and  choroidea  are  divided,  the  vitreous 
humour  immediately  issues  from  the  wound,  which  also  bleeds 
profusely.  The  vitreous  cells  become  injected  with  blood,  and  form 
a  fungus-hke  protrusion  from  the  wound.  This  case  is  to  be 
treated  hke  the  former.  Besides  antiphlogistic  means,  the  eyelids 
must  be  kept  shut,  unless  the  injected  protrusion  of  the  hyaloid 
membrane  prevents  this  from  being  accomplished.  A  warm  bread 
and  water  poultice  is  to  be  laid  over  the  lids.  Most  frequently 
vision  is  entirely  destroyed  by  the  loss  of  vitreous  humour,  the  in- 
jury done  to  the  retina,  and  the  violent  inflammation  of  the  eye 
which  follows  the  accident. 


I  SECTION  V. PRESSURE    AND    BLOWS    ON    THE    EYE. 

|j  Beer  relates  the  following  instance  of  the  bad  effects  of  sudden 
pressure  exercised  on  the  eyeball.  "  Some  years  ago,"  says  he,  "I 
was  called  to  a  man,  who  had  previously  enjoyed  excellent  sight, 
but,  a  short  time  before  I  saw  him,  had  in  an  instant  become  to- 
tally Wind  in  both  eyes.  He  happened  to  be  in  a  company  of 
friends,  when  suddenly  a  stranger  stepped  behind  him,  and  clapped 
bis  hands  upon  his  eyes,  desiring  him  to  tell  who  stood  behind 
'him.  Unable  or  unwilling  to  answer  this  question,  he  endeavoured 
jto  remove  the  hands  of  the  other  person,  who  only  pressed  them 
,Lhe  firmer  on  the  eyes,  till  at  length  withdrawing  them  so  as  to  al- 
low the  eyes  to  be  opened,  the  man  found  that  he  saw  nothing, 
i  33 


258 

and  continued  ever  afterwards  blind,  without  any  apparent  lesion 

of  the  eyes."  * 

Blo\\  s  on  the  eye  are  often  productive  of  amaurosis,  without  any- 
visible  change  being  produced  in  the  organ  :  whence  Ave  may  con- 
clude that  the  blow  has  affected  the  retina  by  concussion,  conges- 
tion, extravasation,  or  laceration.  It  is  unfortunate  that  cases  of 
traumatic  amaurosis  are  often  oeglected,  till  the  bhndness  is  com- 
pletely confirmed  ;  for  much  may  be  done  for  their  relief,  if  they 
are  taken  in  proper  time.  The  following  case  will  illustrate  the 
danger  of  neglect,  and  the  good  effects  of  appropriate  treatment. 

ISlr.  N.  applied  to  me  on  the  ISth  of  January  1S29,  on  account 
of  the  effects  of  a  blow  which  he  had  received,  eight  days  before, 
with  a  prett)^  heavy  piece  of  metal,  on  the  temporal  side  of  the  left 
eye.  He  was  a  man  of  about  40  years  of  age,  of  sound  constitu- 
tion, and  his  eyes  had  been  good  till  this  accident.  Any  inflam- 
mation or  irritation  produced  by  the  blow  had  already  subsided. 
although  almost  nothing  had  been  done  in  the  way  of  treatment. 
The  vision  of  the  eye  was  lost,  except  when  he  turned  it  very  much 
to  the  left,  so  much  indeed  as  to  look  almost  behind  him.  When 
he  did  so.  he  saw  indistinctly  any  object  situated  to  his  left.  For- 
wards or  to  the  right  he  saw  nothing,  every  thing  being  darkened 
by  the  appearance  of  a  thick  gauze  or  mist.  A  bright  light,  as  a 
gas  flame,  was  the  only  object  capable  of  producing  a  sensation,, 
when  the  eye  was  directed  forwards.  This  amaurosis  was  so  con- 
siderable, and  had  been  neglected  for  so  many  days,  that  I  pro- 
nounced a  very  doubtful  prognosis,  but  urged  the  adoption  of  activer 
measures.  Thirt}'  ounces  of  blood  were  taken  from  the  arm  on 
the  evening  of  the  ISth.  He  took  two  of  the  following  pills,  and 
was  ordered  two  three  times  a  day  :  R  aloes  gr.  ii..  massee  pilulse 
hydrargA'ri  gr.  iii.;  misce  ;  fiat  pilula.  On  the  19th.  he  thought 
he  saw  objects  somevrhat  less  indistinctly,  but  still  only  when  he 
looked  much  to  the  left  hand.  "When  he  looked  forwards,  he  saw 
as  if  gauze-threads  were  moving  before  him.  and  the  lamp  appeared 
of  various  colours.  Twenty-four  leeches  were  apphed  round  the 
eye.  On  the  20th,  his  vision  was  so  far  improved,  that  he  could 
make  out  the  large  characters  on  the  back  of  a  quarto  book,  when 
he  looked  at  it  sideways.  He  could  recognise  any  ordinary  object, 
as  a  teacup,  held  towards  his  left  side,  but  lost  sight  of  it  entirely  as 
it  was  moved  in  front  of  him.  A  blister  was  applied  to  the  left 
temple  and  behind  the  left  ear.  On  the  22d,  there  was  a  great 
unprovement  in  vision.  He  could  now  tell  the  hour  on  a  watch, 
even  when  he  looked  straight  forwards,  and  compared  the  apparent 
impediment  to  vision  to  branches  of  trees,  whereas  it  formerl}"  had 
the  appearance  of  a  imiforra  cloud.  The  mouth  being  considerably 
affected  by  the  pills,  they  were  omitted.  The  blister  was  re-applied. 
On  the  24th,  the  bhster  was  discharging  well,  the  mouth  was  very 

*  Pflege  gesunder  und  geschwachter  Augen,  p-  10.     Frankfort,  1802. 


259 

sore,  and  the  vision  much  improved.  He  could  read  a  newspaper 
with  the  left  eye,  and  said  that  the  branches  of  trees,  which  appear- 
ed before  him,  were  now  broken,  and  looked  like  grains  of  sand 
separated  one  from  another.  On  the  26th,  he  stated  that  he  knew 
an  increase  of  vision  daily.  The  mouth  was  still  very  sore.  The 
blister  was  repeated.  After  this,  the  vision  continued  progressively 
to  improve,  and  by  the  middle  of  February  was  all  but  perfect. 

If  it  were  necessary,  I  could  quote  similar  cases  from  the  journals 
of  the  Eye  Infirmary,  showing  the  good  effects  of  depletion,  coun- 
ter-irritation, and  mercurialization,  in  amaurosis  consequent  to  those 
blows  on  the  eye,  which  are  probably  productive  of  congestion  of 
the  choroid  and  retina,  but  unattended  by  any  other  considerable 
lesion  of  these  important  structures. 

I  have  already,  in  the  preceding  sections  of  this  chapter,  had 
occasion  to  notice  some  very  serious  effects  of  blows  on  the  eye,  as 
displacement  and  separation  of  the  iris,  bursting  of  the  capsule  with 
escape  of  the  lens,  and  dislocation  of  the  lens  enclosed  in  the  cap- 
sule. Effusion  of  blood  into  the  aqueous  chambers,  dissolution  of 
the  vitreous  humour,  and  laceration  of  the  retina,  are  among  the 
most  common  effects  of  heavy  blows  on  the  eye.  We  also  fre- 
quently meet  with  laceration  of  the  sclerotica,  with  or  without  rup- 
ture of  the  conjunctiva,  and  of  the  choroid  :  and  sometimes,  though 
not  so  frequently,  we  meet  with  laceration  of  the  cornea.  From 
the  cases  which  have  come  under  my  care,  I  could  describe  an 
almost  infinite  variety  of  effects  arising  from  blows  on  the  eye, 
with  the  fist,  with  sticks,  with  stones,  and  other  implements  thrown 
at  the  eye,  and  from  falls  on  the  eye.  In  the  whole  of  such  cases, 
the  prognosis  is  unfavourable.  Even  when  there  appears  to  be 
nothing  more  than  an  effusion  of  blood  into  the  aqueous  chambers, 
we  generally  find,  that  after  the  blood  is  absorbed,  the  pupil  remains 
dilated  and  immovable,  and  the  retina  insensible.  If  we  puncture 
the  cornea  in  cases  of  this  kind,  there  is,  in  general,  a  profuse  dis- 
charge of  bloody  watery  fluid ;  if  the  puncture  is  small,  it  heals  in 
twenty-four  hours,  and  may  be  repeated  from  time  to  time  without 
any  ill  effects.  The  cornea  is  more  resisting  than  the  sclerotica. 
The  conjunctiva,  from  its  laxity,  sometimes  escapes,  while  the 
sclerotica,  owing  to  the  tension  produced  by  its  contents,  is  unable 
to  withstand  the  effects  of  a  blow,  and  consequently  gives  way. 
I  have  seen  the  sclerotica  and  choroid  ruptured,  and  the  lens  at  the 
same  time  propelled  through  the  lacerated  opening  in  their  tunics, 
so  as  to  lie  immediately  under  the  conjunctiva,  which  remained 
entire.  What  rendered  this  case  the  more  remarkable,  the  iris  had 
been  partly  separated  from  the  choroid  by  a  former  injury,  so  as  to 
form  a  false  pupil,  and  yet  a  considerable  degree  of  vision  was 
ultimately  retained,  as  much,  indeed,  as,  in  many  instances,  is 
recovered  after  an  operation  for  cataract.  I  removed  the  lens  by 
an  incision  through  the  conjunctiva,  some  time  after  the  lacerated 
sclerotica  and  choroid  had  closed. 


260 

In  cases  of  bursting  of  the  eye  from  a  blow,  whether  the  lacera- 
tioa  is  through  the  cornea,  or  through  the  sclerotica,  considerable 
haemorrhage  takes  place,  especially  wlien  the  clioroid  has  also  given 
way.  The  humours  are  also  often  partly,  and  sometimes  almost 
wholly,  evacuated,  so  that  a  dwarfish  deformed  eyeball  is  left  after 
the  lacerated  part  heals  up. 


SECTIOX  VI. GrXSHOT  WOUNDS  OF  THE  ETE. 

Under  this  head,  I  may  notice  some  of  the  effects  of  gunpowder 
exploded  into  the  eye.  It  is  generally  the  lower  portion  of  the 
cornea  which  suffers  most  from  this  accident,  but  in  an  instance 
which  came  under  my  observation,  as  the  person  was  in  the  act  of 
stooping  to  the  ground  when  the  powder  exploded,  only  the  upper 
half  of  each  cornea  received  the  injury,  and  was  left  opaque.  I 
have  repeatedly  seen  grains  of  powder  propelled  through  the  cornea 
into  the  lens,  so  as  to  cause  cataract. 

Small-shot  not  unfrequently  pass  through  the  coats  of  the  eye. 
Demours  has  represented  a  case  in  which  a  grain  of  small-shot 
passed  through  the  cornea,  detached  the  iris  from  the  choroid,  and 
produced  opacity  of  the  lens.*  Amaurosis  is  generally  the  effect 
of  grains  of  shot  entering  the  eyeball ;  and  Mr.  Lawrence  mentions 
that  he  once  saw  complete  blindness  caused  by  a  single  grain, 
which  merely  struck  the  sclerotic  obliquely  and  did  not  enter.t 

The  eyeball  is  most  frequently  found  to  be  burst  in  cases  where 
it  has  been  struck  by  musket-shot ;  but  occasionally  it  escapes,  and 
the  ball  penetrates  between  the  eye  and  the  orbit.  Exophthalmia, 
or  inflammatory  disorganization  of  the  eye,  with  protrusion,  is  very 
apt  to  follow  in  either  of  these  cases.  When  this  symptom  does 
occur,  either  the  humours  should  be  evacuated  by  a  free  and  deep 
incision,  so  as  to  allow  the  eyeball  to  shrink  and  become  quiet ;  or, 
if  it  has  become  solid  from  thickening  of  its  coats,  it  ought  to  be 
extirpated.  If  such  practice  is  not  followed,  the  patient  is  generally 
doomed  to  suffer  extreme  pain  for  a  length  of  time  :  and  the  en- 
larged eyeball  is  even  apt,  by  pressure,  to  produce  absorption  of  the 
roof  of  the  orbit,  and  fatal  inflammation  of  the  dura  mater  and 
brain. 


SECTION    VII. DISLOCATION    OF    THE    EYEBALL. 

I  have  already  had  occasion  to  quote  two  cases  of  dislocation  of 
the  eyeball,  produced  by  foreign  substances  thrust  between  the  eye 
and  the  orbit ;  t  and  I  have  explained  that  by  being  dislocated  is  to 
be  understood  that  the  eyeball  is  extruded  beyond  the  fibrous  layer  of 

*  Traite  des  Maladies  des  Yeux.     Planche  52.     Fig.  1.     Paris,  1818. 
t  Lectures  in  the  Lancet,  Vol.  is.,  p.  531.     London,  1826. 
t  See  pages  13  and  15. 


261 

ihe  eyelids.  The  optic  nerve,  when  the  eye  is  in  that  state,  is  put 
very  much  on  the  stretch,  vision  is  lost  till  reduction  is  accomplish- 
ed, and  the  lids  can  no  longer  be  brought  together. 

If  the  foreign  body  by  which  the  dislocation  has  been  produced 
be  still  in  the  orbit,  it  must,  of  course,  be  removed  before  reduction 
be  attempted.  After  this  is  effected,  the  eye  is  to  be  pressed  steadily 
back  into  its  place.  The  pressure  being  continued  for  some  time, 
the  eyeball  will  generally  be  found  to  start  suddenly  back  through 
the  aperture  in  the  periosteal  edging  of  the  orbit,  and  vision  to  be 
immediately  restored. 

From  the  obliquity  of  the  base  of  the  orbit,  it  is  evident  that  to- 
wards the  temple  the  eyeball  stands  in  a  considerable  degree  exte- 
rior to  that  cavity  ;  and  hence  it  is  that  a  severe  blow  on  the  eye, 
for  instance,  with  a  racket  ball,  is  capable  of  producing  dislocation. 
Covillard,  in  his  Observations  latro-chnurgiqiies^  relates  a  case  of 
this  sort.  He  tell  us  that  the  dislocation  was  so  complete,  that  when 
he  came  to  visit  the  patient,  immediately  after  the  accident,  he  found 
one  of  his  friends  with  scissors  in  his  hand,  ready  to  cut  the  eye 
away.  Covillard  reduced  it,  and  the  patient's  vision  was  pre- 
served.* 


SECTION    VIII. EVULSION    OP    THE    EYEBALL. 

The  eyeball  is  often  blown  out  by  musket-shot ;  but  cases  of  its 
being  torn  out  of  the  socket  by  other  accidental  means  are  rare.  A 
remarkable  instance  of  this,  however,  is  related  in  the  first  volume 
of  Grafe's  Journal.  A  cart-wheel  went  over  the  side  of  the  head, 
and  tore  out  the  eyeball,  along  with  seven  lines'  length  of  the  optic 
nerve,  the  muscles  of  the  eye  being  left  behind,  and  the  orbit  unin- 
jured. The  patient,  a  man  of  75  years  of  age,  recovered  without 
any  bad  symptom. 


CHAPTER   X. 


THE  OPHTHALMIiE,  OR  INFLAMMATORY  DISEASES  OF  THE 

EYEBALL. 

SECTION    I. THE    OPHTH ALMIjE    IN    GENERAL. 

Under  the  term  inflammation,  a  very  considerable  number  of 
different  phenomena  are  included.  There  is  included,  first  of  all, 
that  state  of  parts  which  is  recognized  by  increased  redness,  un- 
natural heat,  swelling,  and  pai7i.     This,  indeed,  is  strictly  ia- 

*  See  Memoire  sur  plusieures  Maladies  du  Globe  de  I'CEil,  par  Louis ;  in  the 
Memoires  de  I'Academie  de  Chirurgie,  Tome  xiii.  p.  266.  12mo.    Paris,  1774, 


262 

flammation,  characterized  by  its  four  distinct  primary  phenomena. 
The  morbid  changes  which  I  shall  presently  enumerate,  may  be 
regarded  as  so  many  secondary  phenomena,  apt  to  succeed,  but 
which  do  not  necessarily  succeed  to  this,  the  first  stage  of  every  in- 
flammatory disease.  So  long  as  the  part  affected  exhibits  nothing 
else  than  increased  redness,  unnatural  heat,  swelling,  and  pain,  and 
so  long  as  these  continue  to  augment,  the  disease  is  merely  devel- 
oping itself.  An  inflammatory  attack  before,  or  even  when  it  has 
reached  the  greatest  degree  of  violence  of  which  this  first  stage  is 
susceptible,  may,  without  any  new  local  phenomena  being  mani- 
fested, gradually  subside  through  the  means  employed  for  its  cure, 
or  by  the  natural  resolution  of  the  disease.  On  the  other  hand, 
the  disease  may  go  on,  and  manifest  with  greater  or  less  rapidity, 
one  or  more  of  the  following  seven  secondary  phenomena  of  in- 
flammation ;  namely,  effusion,  of  red  blood,  of  colourless  blood,  or 
of  fibrin  ;  adhesion  ;  suppuration,  from  a  secreting  surface,  or  in 
the  form  of  abscess  ;  ulceration  ;  mortijication  ;  grariulation  ; 
and  cicatrization.  The  part  inflamed  may  pass  through  several 
of  these  states  in  succession,  or  several  of  them  may  exist  together 
at  the  same  time. 

Inflammation,  in  whatever  part  of  the  body,  and  consequently 
in  whatever  part  of  the  eye,  it  exists,  may  terminate  in  any  of  the 
processes  now  enumerated.  It  is  also  well  known  that  the  secon- 
dary phenomena  of  inflammation  are  always  modified  according  to 
the  structure  of  the  part  affected.  Every  different  texture  of  the 
eye,  as  it  possesses  both  physical  and  vital  properties  peculiar  to  it- 
self, must  suffer  differently  from  these  several  processes  of  inflam- 
mation. In  many  cases,  the  modifications  of  inflammation  from 
differences  of  texture  in  the  j)arts  affected,  are  displayed  with  much 
distinctness  in  the  e5'^e  ;  in  other  cases,  these  modifications  can  be 
judged  of  only  from  their  consequences,  and  by  a  very  minute  ob- 
servation of  the  derangement  which  remains  in  the  organization 
or  in  the  function  of  the  part  which  had  suffered  ;  while  in  other 
cases,  from  the  delicate  texture  of  the  part  or  its  hidden  situation 
in  the  eye,  the  modifications  in  question  may  altogether  escape  ob- 
servation. 

The  conjunctiva,  sclerotica,  cornea,  iris,  chrystalline  capsule,  and 
retina,  present  a  series  of  the  modifications  of  inflammation,  to 
which  I  have  just  now  referred,  sufficiently  distinct  to  convince  the 
most  sceptical  of  the  truth  of  what  I  have  been  asserting,  and  suf- 
ficiently striking  to  rouse  the  most  inattentive  to  research.  The 
muco-cutaneous  conjunctiva  secreting  a  flood  of  purulent  matter,  as 
in  the  ophthalmia  of  newborn  children — the  fibrous  sclerotica  af- 
fected for  months  with  rheumatic  inflammation — the  transparent 
fibro-cartilaginous  cornea  becoming  opaque,  or  being  destroyed  layer 
after  layer  by  a  penetrating  ulcer — the  erectile  iris  losing  all  power 
of  executing  its  motions  of  expansion  and  contiaction — the  chrys- 
talline capsule  pouring  out  coagulable  lymph  from  its  serous  surface. 


263 

and  this  lymph  forming  the  medium  of  morbid  adhesions — the 
nervous  retina,  too  deeply  seated  to  be  observed  immediately,  but 
in  a  few  hours  losing  its  inconceivably  delicate  sensibility — these 
are  facts  in  which  are  displayed  the  modifications  of  inflammatory 
action  and  the  various  consequences  of  inflammation,  fully  as  dis- 
tinctly and  as  strikingly  as  they  are  manifested  in  any  other,  nay 
in  all  the  other  parts  of  the  body  put  together. 

There  are  other  circumstances  besides  differences  of  texture 
which  modify  the  inflammatory  affections  of  the  eye,  -and  which 
render  this  subject  very  extensive  in  the  discussion,  and  cause  the 
diseases  to  be  occasionally  very  perplexing  in  the  treatment.  They 
are  under  the  influence  of  peculiarities  of  constitution,  of  constitu- 
tional diseases,  and  of  certain  artificial  states  of  constitution ;  and 
they  are  subject  to  innumerable  variations  from  the  influence  of 
those  inscrutable  connexions  called  sympathies.  Scrofula,  syphilis, 
gout,  and  that  state  of  the  system  which  we  may  call  mercurialism, 
are  each  of  them  either  capable  of  exciting  inflammation  in  differ- 
ent parts  of  the  eye,  or  at  least  of  communicating  to  an  inflamma- 
tion, excited  by  other  causes,  such  differences  in  character  as  shall 
often  render  it  difficult  to  recognise  a  disease  with  which  we  were 
well  acquainted  in  its  simple  or  idiopathic  form. 

By  the  influence  of  local  sympathy,  inflammation  of  one  texture 
of  the  eye  never  takes  place  without  extending  in  some  degree  to 
the  textures  with  which  the  first  affected  is  in  contact ;  by  the 
same  influence,  an  inflammatory  disease  originating  in  one  tex- 
ture of  the  eye  shall  be  communicated  to  several  of  the  other  tex- 
tures, the  inflammation  of  the  superficial  tunics  being  communi- 
cated to  those  more  deeply  seated,  and  conversely  that  of  the  in- 
ternal parts  spreading  outwards ;  and,  while  each  texture  obeys 
its  own  laws  of  morbid  action,  the  whole  organ  in  this  way  maj?" 
become  involved,  by  what  had  at  first  a  very  limited  [existence, 
and  perhaps  a  very  trivial  aspect. 

When  we  jeflect,  then,  on  the  innumerable  combinations  which 
may  take  place  among  the  inflammatory  diseases  of  the  eye,  and 
the  many  causes  by  which  these  diseases  may  be  modified,  we 
shall  be  convinced,  I  think,  that  of  all  the  subjects  requiring  de- 
scriptions and  explanations  of  morbid  actions  and  changes,  there 
can  be  few  more  difl&cult  than  those  diseases  which  have  been  swept 
together  with  so  indiscriminating  a  hand,  under  the  name  of  oph- 
thalmia. To  consider  these  actions  and  changes  individually,  and 
only  in  a  single  texture  of  the  eye  at  once,  may  seem  to  lessen 
the  difficuliy ;  for  instance,  to  consider  inflammation  of  the  cornea, 
and  to  exhibit  to  ourselves  in  order,  effusion  of  serum,  eflTusion  of 
coagulable  lymph,  secretion  of  pus,  formation  of  abscess,  ulceration, 
mortification,  and  cicatrization,  according  as  each  of  these  processes 
manifests  itself  in  the  cornea.  But  to  do  all  this,  is  to  consider  and 
to  exhibit  what  never  takes  place  separately  in  nature.  Unless 
this  be  kept  in  mind  by  those  who  begin  to  study  the  inflammato- 


264 

ry  diseases  of  the  eye,  they  will  be  not  a  little  perplexed  bj''  tha 
diversified  complications  of  morbid  phenomena,  which  they  will 
meet  at  every  step  of  their  progress. 

The  knowledge  of  the  inflammatory  diseases  of  the  eye  has 
been  greatly  retarded  by  the  practice  of  confounding  them  all  under 
the  name  of  ophthalmia,  and  thus  overlooking  both  the  seat  of 
the  disease,  and  the  peculiar  nature  of  the  inflammation.  The 
consequence  of  thus  viewing  all  these  diseases  without  discrimina- 
tion, has  been  a  method  of  treating  them  equally  preposterous. 
In  fact,  in  the  practice  of  those  who  have  had  no  opportunities  of 
studying  the  diseases  of  the  eye,  one  routine  of  remedies  continues 
to  be  used  in  every  case  in  which  the  eye  appears  inflamed,  and 
it  often  happens,  that  it  is  not  till  this  routine  is  exhausted,  and 
the  eye  in  some  of  its  essential  parts  becoming  seriously  disorga- 
nised, that  a  suspicion  arises  of  there  being  somethiog  specific  or 
peculiar  in  the  case.  Even  from  the  slight  view  which  we  have 
akead}''  taken  of  this  subject,  it  is  evidentljf  impossible  that  the  in- 
flammatory affections  of  parts  so  widely  differing  in  structure  and 
function  as  do  those  which  are  assembled  in  the  eye,  can  be  treated 
at  ance  indiscriminately  and  successfully.  We  find,  for  example, 
that  the  remedies  which  in  the  course  of  a  few  days  are  sutficient 
completely  to  remove  inflammation  of  the  conjunctiva,  only  aggra- 
vate inflammation  of  the  sclerotica  or  iris,  while  the  plan  of  treat- 
ment which  speedily  cures  sclerotitis  or  iritis,  if  trusted  to  in  con 
junctivitis,  would  expose  the  eye  to  almost  certain  destruction. 
Great  advantages  will  accrue,  then,  from  the  adoption  of  an  accu- 
rate classification  of  the  ophthalmiee.  One  advantage  of  no  incon- 
siderable moment  will  be,  that  we  shall  conduct  our  examinations 
of  the  inflammatory  diseases  of  the  eye  which  may  come  under 
our  care,  with  much  more  accuracy  than  we  could  possibly  do, 
were  we  to  employ  the  vague  nomenclature  commonly  used  upon 
this  subject.  Having  noted  exactly  the  disease  which  is  before  us, 
we  shall  be  able  bc^h  to  ascertain  to  our  own  satisfaction,  the  ef- 
fects of  the  remedies  which  we  employ,  and  to  communicate  our 
experience  to  others  ;  which,  without  a  just  classification  and  per- 
spicuous nomenclature,  it  is  utterly  impossible  to  do. 

1  have  admitted  into  the  following  table  of  the  ophthalmiee  none, 
the  distinct  and  separate  existence  of  which  I  have  not  either  as- 
certained in  the  course  of  my  own  observations,  or  beenxonviuced 
of  upon  indubitable  authority. 

I.  CONJUNCTIVITIS. 

I.  Conjunctivitis  PuRO-MrcosA. 

1.  Catarrhal. 

2.  Contagious  or  Egyptian, 

3.  Leucorrhoeal,  or  Ophthalmia  Neonatorum. 

4.  Gonorrhoeal. 

II.  Conjunctivitis  Scrofulosa. 


265 

1.  Phlyctenular. 

2.  Pustular. 

III.  Conjunctivitis  Erysipelatosa. 

IV.  Conjunctivitis  Variolosa, 

V.  Conjunctivitis  Morbillosa. 

VI.  Conjunctivitis  Scarlatinosa. 
II.  SCLEROTITIS. 

1,  Rheumatic. 

III.  CORNEITIS. 
1.  Scrofulous. 

IV.  IRITIS. 

1.  Rheumatic. 

2.  Syphilitic. 

3.  Scrofulous. 

4.  Arthritic. 

V.  CHOROIDITIS. 

VI.  RETINITIS. 

VII.  AdUO-CAPSULITIS. 

VIII.  ANTERO-CHRYSTALLINO-CAPSULITIS. 
IX.  POSTERO-CHRYSTALLINO-CAPSULITIS. 
X.  VITREO-CAPSULITIS. 
XI.  CHRYSTALLINITIS. 

Appendix. 

1.  Traumatic  Ophthalmiae. 

2.  Compound  Ophthalmiae,  as  the  catarrho-rheumatic,  pus- 
tulo-catarrhal,  &c. 

3.  Intermittent  Ophthalmiae. 


section  ii. — remedies  for  the  ophthalmiae. 

Before  proceeding  to  describe  the  different  inflammations  of  the 
eye,  and  explain  the  treatment  peculiarly  required  for  each,  it  may 
not  be  improper  to  offer  a  few  rules  of  universal  application  in  the 
treatment  of  these  diseases,  and  to  make  some  general  remarks  on 
the  classes  of  remedies  employed  for  their  cure. 

1.  It  is  a  general  rule  of  great  importance  in  the  treatment  of 
any  ophthalmia,  to  discover  the  cause  whence  it  has  arisen,  and,  if 
possible,  to  remove  that  cause,  if  it  is  still  in  operation.  The  cause 
may  be  purely  local,  or  it  may  be  constitutional ;  but  in  either  case, 
if  it  be  allowed  still  to  operate,  it  is  evident  that  every  thing  in  the 
way  of  remedy  must  prove  comparatively  or  entirely  ineffectual. 

2.  The  eye,  and  the  body  at  large,  must  be  defended  from  new 
causes  of  irritation.  The  original  cause  may  be  removed,  but  still 
the  disease  may  continue,  being  kept  up  by  other  causes  of  a  nature 
very  different  from  the  original  one,  but  equally  detrimental.  The 
primary  cause  is  often  local,  and  the  secondary  causes  constitutional. 
After  the  first  is  removed,  the  second  are  too  often  overlooked. 

34 


266 

The  remedies  which  may  occasionally  be  required  for  the  cure  of 
the  ophthalraise  are  very  numerous ;  those  which  are  most  frequent- 
ly used,  and  in  general  with  complete  success,  are  few  and  simple. 

1.  Bloodletting.  Openiv:r  a  vein  of  the  arm,  the  apphcation  of 
leeches  round  the  eye,  and  division  of  the  inflamed  conjunctiva,  are 
the  three  modes  of  taking  away  blood  generally  had  recourse  to  in 
this  class  of  diseases.  Opening  the  temporal  artery,  the  external 
jugular  vein,  or  the  nasal  vein,  or  cupping  the  temples,  is  seldom 
necessary.  The  three  modes  of  bleeding  first  enumerated,  cannot 
be  substituted  one  for  another,  and  we  should  often  run  a  risk  of 
losing  the  ej'e,  were  we  to  attempt  to  cure  by  local  what  will  readily 
yield  to  general  bleeding,  or  vice  versa.  For  instance,  bleeding  at 
the  arm.  by  depressing  the  general  strength  of  the  patient,  rather 
aggravates  than  alleviates  the  scrofulous  ophthalmias,  v.'hile  bleeding 
with  leeches,  by  removing  local  turgescence,  greatly  relieves  them  ; 
a  check  is  readily  put  to  most  of  the  internal  ophthalmiee  by  gene- 
ral blood-letting,  while  local  has  comparatively  but  little  effect ;  in 
chronic  puro-mucous  conjunctivitis,  much  more  good  is  done  by 
scarifying  the  inside  of  the  eyelids,  than  could  be  accomplished  by 
leeching  or  phlelxttomy.  Neither  is  it  unimportant  in  what  succes- 
sion we  employ  these  three  modes  of  taking  away  blood.  Leech- 
ing, for  example,  when  considerable  synocha  is  present,  produces 
much  more  effect  if  preceded  by  general  bleeding  ;  and  especially  if 
.the  leeches  are  applied  within  a  few  hours  after  the  impetus  of  the 
circulating  system  has  been  moderated  by  bleeding  from  the  arm. 

I  know  of  no  inflammatory  disease  of  the  eye  which  is  curable 
by  bleeding  alone ;  and  I  look  on  the  attempts  to  cure  the  conta- 
gious or  Egyptian  ophthalmia  by  taking  away  very  large  quantities 
of  blood,  till  the  inflamed  membrane  grows  pale  from  depletion, 
as  the  veriest  of  folly ;  first,  because  even  were  this  paleness  pro- 
duced, it  could  be  no  test  of  the  disease  being  subdued ;  secondly, 
because  a  degree  of  blood-letting  suflacient  to  produce  even  an  ap- 
proach to  such  an  effect,  would  leave  the  patient  in  a  state  of  great 
and  unnecessary  debility :  and  thirdly,  because  the  disease  could  be 
cured  by  a  much  milder  plan  of  treatment.  AU  the  ophthalmise 
require  other  remedies  besides  the  taking  away  of  blood  ;  and,  there- 
fore, while  we  value  this  means  of  cure  veiy  highly,  we  must  by 
no  means  trust  to  it  alone  in  any  case. 

In  taking  away  blood  from  the  arm  in  any  inflammatory  disease 
of  the  eye,  the  opening  should  be  made  large,  so  to  ensure,  if  pos- 
sible, a  consideral^le  effect  on  the  impetus  of  the  circulation.  The 
quantity  removed  will  vary  from  ten  to  thirty  or  forty  ounces,  ac- 
cording to  the  constitution  of  the  patient,  and  the  circumstances  of 
the  disease. 

Leeches  ought  to  be  appUed,  in  general,  not  on  the  loose  sub- 
stance of  the  eyelids,  but  on  the  temple,  forehead,  and  side  of  the 
nose.  The  number  applied  will  vary  from  one  to  twenty  or  more. 
In  infants,  we  often  find  much  good  effected  by  one  leech  to  the 


267 

middle  of  the  upper  eyelid.  In  some  chronic  cases  of  inflamed 
and  thickened  conjunctiva,  one  or  two,  fixed  on  the  internal  surface 
of  the  lids,  will  be  found  useful. 

I  by  no  means  deny  the  efficacy  of  opening  the  temporal  artery, 
or  taking  away  blood  by  scarifying  and  cupping  the  temples ;  but 
these  modes  are  more  difficult  of  execution,  and  are  attended  with 
a  greater  degree  of  irritation  and  pain  than  simple  venesection,  and 
the  application  of  leeches.  They  also  preclude,  in  many  instances, 
the  use  of  other  means  which  are  likely  to  be  useful ;  as,  blisters 
to  the  temple  and  behind  the  ear.  The  tight  bandage  necessary 
after  arteriotomy  is  also  objectionable  in  cases  of  ophthalmiee,  as  it 
produces  a  degree  of  pressure,  and  a  development  of  heat,  which 
are  apt  to  increase  the  uneasiness  of  the  eye  and  head. 

Scarification  of  the  conjunctiva  of  the  eyelids,  and  sometimes  of 
that  covering  the  eyeball,  is  a  valuable  means  of  cure  in  certain 
cases.  One  or  two  deep  incisions  being  made  along  the  whole 
length  of  the  inner  surface  of  either  eyelid,  a  very  considerable  dis- 
charge of  blood  will  probably  take  place,  and  if  the  lids  be  proper]  y 
managed,  blood  will  continue  to  flow  for  a  considerable  time.  F  or 
this  purpose,  the  lid  ought  neither  to  be  held  everted  till  the  bleeding 
ceases,  nor  allowed  to  fall  back  into  continued  contact  with  the 
eyeball,  in  either  of  which  ways  little  blood  will  be  obtained  ;  but 
the  lid  ought  to  be  alternately  everted  and  permitted  to  return  to 
its  natural  position,  by  which  means  the  divided  vessels  are  re-filled, 
and  thus  a  continued  flow  of  blood  is  produced. 

Along  with  scarification,  we  may  class  the  snipping  across  of 
individual  enlarged  vessels  running  over  the  surface  of  the  eyeball,, 
which  is  often  useful.  The  mode  which  I  adopt,  is  to  raise  a  small 
fold  of  the  conjunctiva  with  the  forceps,  and  snip  it'away  wadi  the 
scissors.  This  fold  rarely  contains  the  enlarged  vessel  which  w^e 
wish  to  cut  across,  but  it  is  now  exposed ;  wath  a  small  hook  it  is 
easily  raised  from  the  surface  of  the  sclerotica,  and  divided. 

The  practice  of  removing  with  the  scissors  a  circular  portion  of 
the  conjunctiva  round  the  edge  of  the  cornea,  as  was  advised  by 
Scarpa,  appears  to  be  almost  laid  aside. 

Evacuating  the  aqueous  humour,  as  a  mode  of  depletion  in  cer- 
tain kinds  of  ophthalmia,  was  highly  recommended  by  Mr.  Ward- 
rop ;  but  has  never  come  into  general  use. 

2.  Purgatives  act  in  two  ways  in  the  cure  of  the  inflammatory 
disease  of  the  eye ;  namely,  as  depletory,  and  as  sympathetic  means. 
They  reduce  the  quantity  of  circulating  fluid,  as  well  as  remove 
the  contents  of  the  bowels  ;  and  from  the  continuity  of  the  investing 
membrane  of  the  eye  with  the  lining  membrane  of  the  digestive 
organs,  they  prove  a  very  effectual  remedy  in  almost  all  kinds  of 
ophthalmia.  An  active  purge  of  calomel  and  jalap  is  often  suffi- 
cient of  itself  to  check  an  attack,  when  employed  early.  In  the 
course  of  diseases  of  this  class,  occasional  laxatives  are  always 
necessary ;  while  in  many  cases,  especially  in  children,  nothing 
but  a  continued  use  of  purgatives  will  effect  a  cure. 


268 

3.  Emetics  are  of  essential  service  in  the  treatment  of  various 
inflammatory  affections  of  the  eye,  not  only  when  there  is  reason 
to  suppose  that  an  overloaded  state  of  the  digestive  organs  is  con- 
cerned in  keeping  up  irritation,  but  as  a  means  of  lowering  the 
circulation,  and  relaxing  the  skin.  In  chronic  cases,  the  sorbe- 
facient  effects  of  this  class  of  remedies  are  also  highly  useful,  pro- 
moting the  absorption  of  unhealthy  depositions,  and  thus  assisting 
in  restoring  the  transparent  media  of  the  eye  to  their  natural 
condition. 

4.  Diaphoretics  are  useful  in  lowering  inflammatory  action  in 
the  eye,  especially  when  suppressed  perspiration  has  been,  as  it 
often  is,  the  exciting  cause  of  an  ophthalmia.  The  eye,  being 
invested  by  a  continuation  of  the  integuments,  partakes  in  the 
good  effects  of  a  renewed  secretion  from  the  skin.  We  seldom, 
indeed,  think  of  treating  any  ophthalmia  by  diaphoretics  alone ; 
but,  after  depletion,  we  employ  this  class  of  remedies  as  valuable 
adjuvants  in  the  cure. 

5.  Alteratives.  Of  this  class  mercury  is  the  chief;  and  without 
the  aid  of  this  medicine,  we  might  regard  the  internal  ophthalmias, 
and  especially  inflammation  of  the  iris,  as  incurable.  It  is  as  a 
sorbefacient  that  mercury  proves  so  useful  in  the  internal  ophthal- 
mise,  powerfully  promoting  the  removal  of  effused  coagulable  lymph, 
by  an  increased  action  of  the  absorbents.  Whether  it  accomplishes 
this  directly,  by  actually  stimulating  the  absorbents,  or  merely 
favours  their  action,  by  abating  in  some  unknown  mode,  the  in- 
flammation, in  which  the  effusion  originates,  we  are  unable  to  say ; 
but  the  sad  result  of  the  ophthalmiee  of  this  class  when  neglected, 
and  the  admirable  effects  of  mercury,  in  preserving  the  open  and 
transparent  state  of  the  pupil,  in  these  diseases,  are  placed  beyond 
all  doubt. 

In  the  diseases  to  which  I  have  alluded,  we  employ  mercury  so 
as  to  affect  the  constitution,  and  in  this  way  to  operate  on  the  eye  ; 
but  in  other  cases  we  use  it  in  smaller  doses,  in  the  expectation  of 
deriving  benefit  from  its  well  known  effects  on  the  secretory  organs 
concerned  in  digestion. 

6.  Tonics.  The  scrofulous  ophthalmiee,  and  almost  all  others 
in  the  chronic  stage,  are  benefited  by  this  class  of  medicines,  of 
which  cinchona  is  by  far  the  most  powerful.  The  treatment  of 
the  scrofulous  opthalmise  with  sulphate  of  quina  is  an  improvement 
in  ophthalmic  medicine,  perhaps  scarcely  less  important  than  the 
treatment  of  iritis  with  mercury.  The  former  diseases  are-  much 
more  frequent  in  their  occurrence  than  the  latter,  and  not  less  dan- 
gerous in  their  effects  upon  the  transparent  parts  of  the  eye. 

The  mineral  acids,  and  the  chalybeates,  are  also  highly  valuable 
tonic  remedies  for  certain  kinds  and  stages  of  the  ophthalmiae. 

7.  Narcotics.  We  are  naturally  led  to  employ  narcotics  in  the 
hope  of  assuaging  the  severe  pain  attending  many  of  the  ophthal- 
miee ;  but  this  is  perhaps  not  their  most  important  effect.     Two  of 


269 

tlie  most  painful  ophthalmise  are  the  rheumatic  and  catarrho-iheu- 
matic.  Laudanum,  rubbed  on  the  forehead  and  temple,  does  much 
to  reheve  the  pain  ;  or  if  opium  be  taken  internally,  considerable 
alleviation  will  be  procured  ;  and  much  more  good  will  be  effected 
if  this  medicine  be  administered  internally,  combined  with  calomel. 
I  regard  the  form  of  calomel  with  opium  as  almost  specific  in  the 
rheumatic  and  catarrho-rheumatic  ophthalmiee.  Either  remedy  by 
itself  is  much  less  efficacious.  The  opium  appears  to  act  as  much 
as  a  dirigent  as  a  narcotic. 

Opium,  in  vapour,  and  in  fomentation,  is  employed  directly  to 
the  eye  in  certain  states  of  inflammation. 

A  very  peculiar  set  of  narcotics,  of  inestimable  value  in  ophthal- 
mic medicine,  consists  of  belladonna,  hyoscyamus,  and  stramonium, 
which  have  the  power  of  dilating  the  pupil.  They  are  used  in  a 
variety  of  ways,  but  chiefly  in  extract  smeared  on  the  eyebrow. 
As  in  all  the  internal  ophthalmiee  there  is  a  disposition  to  closure 
of  the  pupil,  one  of  these  narcotics  is  applied  once  or  oftener  in  the 
twenty-four  hours  to  oppose  this  tendency.  If  severe  inflammation 
is  already  present  in  the  iris,  they  have  little  effect ;  but  if  the  at- 
tack is  incipient,  or  if  it  be  already  yielding  to  the  influence  of 
mercury,  the  pupil  is  speedily  expanded. 

8.  Refrigerants.  Prom  the  feeling  of  unnatural  heat  which 
attends  most  of  the  ophthalmiee,  the  application  of  cold  water  may 
be  regarded  as  a  remedy  to  which  the  patient  is  prompted  by  in- 
stinct. It  undoubtedly  relieves  for  a  time,  yet  in  the  internal  oph- 
thahniee  it  is  positively  injurious,  while  in  many,  or  even  in  most 
other  cases,  there  follows  its  use  a  degree  of  reaction  which  is  det- 
rimental. Incipient  inflammation  of  the  external  covering  of  the 
eye  may  sometimes  be  checked  by  the  application  of  cold  lotions  ; 
but  even  in  these  cases,  the  same  good  may  be  obtained  from  tepid 
applications,  without  the  risk  of  any  hurtful  re-action  ;  exactly  as 
the  skin  in  fever  is  cooled  with  less  risk  by  the  tepid,  than  by  the 
cold  affusion.  A  tepid  lotion  soothes  and  relaxes  the  inflamed 
membranes  of  the  eye,  and  being  evaporated  at  the  expense  of  the 
superabundant  heat  of  the  parts,  acts  in  fact  as  a  refrigerant. 
Hence  it  is  that  I  scarcely  ever  employ  cold  applications  or  refrige- 
rant solutions  in  the  treatment  of  the  ophthalmise. 

Nitre  is  occasionally  employed  as  an  internal  refrigerant  in  some 
ophthalmise.     Its  diuretic  effects  may  perhaps  prove  serviceable. 

9.  Astringents.  I  have  almost  entirely  dismissed  from  my  prac- 
tice the  acetas  plumbi,  and  sulphas  zinci,  being  convinced,  from 
numerous  observations,  of  their  almost  uniform  bad  effects,  especi- 
ally if  they  are  allowed  to  come  into  contact  with  the  cornea  in  an 
abraded  or  ulcerated  state.  The  nitras  argenti  and  murias  hydrar- 
gyri,  in  solution,  may  be  substituted  in  place  of  almost  all  other 
astringent  lotions  or  drops.  Even  the  sulphas  cupri  and  lapis  di- 
vinus  may  be  laid  aside,  except  in  a  few  peculiar  cases. 

10.  Stimulants  and  escharotics.  Under  this  head  we  include 


270 

a  valuable  set  of  remedies  ;  as,  nitras  argenti,  murias  hydrargyri, 
red  precipitate,  subnitrate  of  mercury,  vinum  opii,  &c.  In  the  in- 
ternal ophthalmise,  the  application  of  most  of  these  is  destructive, 
while  in  conjunctival  inflammations,  more  is  effected  by.  their 
means  than  by  almost  any  other  kind  of  remedy.  The  nitras  argenti 
and  murias  hydrargyri  are  to  be  employed  in  solution,  never  in  the 
form  of  ointment.  No  doubt  a  nitras  argenti  ointment  has  been 
recommended  by  Mr.  Cleoburey  and  others,  but  as  it  is  perpetually 
imdergoing  a  new  degree  of  decomposition,  it  forms  a  remedy  of 
variable  strength,  concerning  the  effects  of  which  no  certain  con- 
clusions can  be  drawn.*  The  red  precipitate,  again,  and  the  sub- 
nitrate  of  mercury,  are  used  only  in  the  form  of  salves.  The  vinum 
opii  is  applied  either  pure  or  diluted,  and  in  certain  chronic  inflam- 
mations of  the  eye  proves  highly  useful.  Any  attempt  to  employ 
it,  or  indeed  any  other  single  remedy,  as  a  panacea  in  the  ophthal- 
miae,  would  manifest  a  total  ignorance  both  of  this  class  of  dis- 
eases, and  of  the  uses  of  remedial  agents. 

11.  Counter-irritants,  including  rubefacient  hniments,  blisters, 
and  issues,  are  of  much  service  in  the  treatment  of  the  ophthalmiee, 
especially  in  the  chronic  stage. 

Having  thus  gone  over  the  chief  classes  of  remedies  employed 
in  the  treatment  of  the  ophthalmiee,  I  may  mention  that  much 
is  to  be  effected  also,  in  the  cure  of  these  diseases,  by  dietical 
regulations,  using  dietical  in  its  original  and  extended  sense,  and 
comprehending  under  it  every  particular  in  the  mode  of  life. 
Thus,  attention  to  cleanliness,  by  the  removal  of  morbid  discharges 
from  the  eyes,  e>zclusion  from  an  improper  degree  of  light,  exposure 
to  pure  air  frequently  renewed,  early  going  to  rest,  quiet  sleep, 
repose  of  body  and  mind,  a  properly  regulated  diet,  and  regulated 
exercise ;  all  these,  and  many  similar  observances,  are  in  a  high 
degi'ee  conducive  to  recovery,  while  a  neglect  of  one  or  more  of  these 
rules  is  often  the  cause  of  prolonged  and  severe  attacks  of  inflam- 
mation, in  different  textures  of  the  e3'e. 


SECTIOX  III.- — CONJUNCTIVITIS  IN  GENERAL. 

It  may  here  be  proper  io  recall  to  mind  the  extent  and  relations 

of  the  conjunctiva,  that  it  lines  the  internal  surface  of  each  eyelid, 

*  The  following  note  is  taken  from  the  preface  of  the  original  edition. 

Notwithstanding  this  objection,  which,  in  a  pharmaceutical  point  of  view,  is  im- 
portant, I  have  been  induced  to  try  a  salve  composed  of  five  grains  of  nitrate  of  silver, 
rubbed  into  an  impalpable  powder,  and  mixed  with  an  ounce  of  lard;  and,  in  chronic 
cases  of  the  puro-mucous  ophthalmia,  have  found  it  highly  beneficial.  In  the  acute 
stage  of  these  diseases,  the  aqueous  solution  still  appears  preferable. 

The  fact  that  lard  slowly  decomposes  nitrate  of  silver,  of  course  renders  it  expedient 
to  prepare  this  ointment  only  in  small  quantity  as  it  is  wanted.  At  first  it  consists 
simpl}'  of  nitrate  of  silver  in  fine  powder  diiTused  in  lard,  but  afterwards  the  nitrate  is 
slowly  reduced,  by  the  action  of  the  animal  substance,  to  the  state  of  an  oxide. 

The  salve  is  apphed  once  a-day  to  the  inflamed  conjunctiva,  and  generally  produces 
very  considerable  pain  for  abou;,  a  quarter  of  an  hour. 


271 

covers  the  anterior  third  of  the  eyeball,  passes  over  the  cornea, 
although  differing  considerably  in  texture  at  that  part  from  what  it 
is  in  the  rest  of  its  extent,  that  it  insinuates  itself  into  the  excretory 
ducts  of  the  lachrymal  glaud,  forms  a  semilunar  fold  at  the  inner 
angle  of  the  eyelids,  covers  the  caruncula  lachrymaUs,  invests  the 
Meibomian  follicles,  enters  into  their  apertures,  and  passes  into  the 
lachrymal  canals  by  the  puncta  lachrymalia. 

This  muco-cutaneous  membrane  is  occasionally  affected  \nth  in- 
flammation like  that  by  which  the  other  parts  of  the  mucous  system 
are  commonly  attacked  ;  a  puro-mucous,  blenorrhoeal,  or  catarrhal  in- 
flammation ;  and  in  other  cases,  it  is  affected  with  diseases  evidently 
partaking  of  the  nature  of  cutaneous  eruptions.  It  thus  resembles 
the  membrane  of  the  fauces,  which  sometimes  is  affected  with 
catarrhal  inflammation,  and  at  other  times  with  aphthae ;  or  the 
continuation  of  the  lining  membrane  of  the  urethra  over  the  glans 
penis,  wiiich  in  one  case  we  see  affected  v»'ith  gonorrhoea,  and  in 
another  with  a  pustular  eruption. 

There  are  certain  marks  by  which  we  distinguish  an  inflamma- 
tion of  the  conjunctiva  from  one  of  the  sclerotica.  The  vessels  of 
an  inflamed  conjunctiva  are  comparatively  large,  and  tortuous,  they 
are  more  of  a  scarlet  colour,  anastomose  freely  with  one  another, 
and  form  a  net-work  over  the  w  hite  of  tire  eye ;  whereas  the  vessels 
of  an  inflamed  sclerotica  are  small  and  hair-like,  never  very  tortu- 
ous, but  run  like  radii  towards  the  cornea,  forming  thus  a  halo  or 
zone,  and  not  a  net-work,  and  are  generally  more  of  a  pink  or  rose, 
than  of  a  scarlet  colour.  The  vessels  of  an  inflamed  conjunctiva 
can  be  shoved,  or  drawn  aside,  by  pressing  or  dragging  the  eyelids, 
and  they  shift  under  the  rotatory  motions  of  the  eyeball ;  whereas 
those  of  the  sclerotica  are  not  susceptible  of  any  of  these  changes 
of  place,  but  whatever  position  the  eye  assumes,  maintain  the  same 
relation  to  the  membrane  on  which  they  run,  and  to  the  cornea, 
although  the  conjunctiva  is  easily  made  to  slide  over  them. 

Here  a  question  naturally  occurs.  Does  the  conjunctiva  remain  un- 
inflamed  in  sclerotitis  7  We  answer,  No.  Neither  does  the  sclerotica 
in  conjunctivitis.  A  common  occurrence  also  in  conjunctivitis,  and 
occasionally  in  sclerotitis,  is  an  effusion  into  the  cellular  membranes 
connecting  the  tv.'^o  tunics,  so  that  the  conjunctiva  is  elevated  from  the 
sclerotica,  which  by  this  means  is  completely  hid  from  view,  so  that 
in  determining  the  genus  of  the  ophthalmia,  in  this  chemosed  state 
of  the  eye,  we  must  be  led  by  other  signs  than  merely  the  appear- 
ances or  arrangement  of  the  inflamed  blood-vessels.  We  take  into 
account  the  original  seat  of  the  inflammatory  action,  and  consider 
which  is  the  part  the  functions  of  which  are  principally  aflfected. 
There  is  undoubtedly  a  sympathy  of  contiguity  which  prevents  a 
conjunctivitis,  or  a  sclerotitis,  or  an  iritis,  from  existing  entirely 
insulated,  and  without  some  participation  of  the  surrounding  parts, 
while  at  the  same  time  it  is  evident  that  the  inflammation  begins 
in  one  part  only,  and  continues  through  the  whole  course  of  the 


272 

disease,  to  affect  that  part  with  much  greater  severity.  We  shall 
see  immediately  also,  that  there  are  certain  subjective  signs  by 
which  we  can  readily  determine  the  genus  of  any  ophthalmia, 
whether  conjunctivitis  or  sclerotitis,  even  although  we  were  not 
allowed  to  inspect  the  inflamed  membranes  at  all. 


SECTION  IV. PURO-MUCOUS  CONJUNCTIVITIS  IN  GENERAL. 

There  are  certain  symptoms  characteristic  of  the  genus  conjunc- 
tivitis puro-mucosa,  whether  it  arise  from  the  influence  of  a  cold 
and  moist  atmosphere,  or  from  contagion,  and  whether  the  conta- 
gion be  derived  from  this  disease  existing  in  the  eye  of  another  per- 
son, or  from  the  appUcation  of  puriform  matter  from  other  quarters, 
as  that  of  leucorrhoea  or  gonorrhoea.  All  these  are  capable  of  ex- 
citing puro-mucous  conjunctivitis,  and  the  last  mentioned  causes 
produce  a  much  more  severe  disease  than  the  first.  The  charac- 
teristic symptoms  of  puro-mucous  conjunctivitis  are  analogous  to 
those  which  attend  the  blenorrhoeal  or  purulent  inflammation  of 
other  mucous  membranes,  as  of  the  Schneiderian  membrane  in 
catarrh,  or  the  lining  of  the  urethra  in  gonorrhoea.  Besides  the 
primary  phenomena  of  inflammation,  there  is  a  suppression  of  the 
natural  mucous  secretion  of  the  inflamed  conjunctiva,  and  a  conse- 
quent feeling  of  dryness  and  itching  in  the  eye ;  nest  follows  a  thin 
and  irritating  discharge ;  then,  a  copious  puriform  discharge,  which, 
after  continuing  for  a  longer  or  shorter  space  of  time  in  different 
instances,  gradually  diminishes,  becomes  thin,  and  at  last  ceases 
entirely,  leaving  the  conjunctiva  in  a  more  or  less  altered  state,  and 
with  a  greater  or  less  disposition  to  the  re-secretion  of  pus. 

The  most  striking  character  of  this  genus  is,  no  doubt,  the  puri- 
form discharge.  I  need  scarcely  say  that  the  pus  is  secreted  by  the 
conjunctiva;  it  is  merely  an  increased  and  changed  discharge  of 
mucus,  and  not  the  effect  of  ulceration.  It  is  also  almost  superflu- 
ous to  mention,  that  the  inflammation  of  the  conjunctiva,  although 
ficculiar,  is  still  sufficiently  distinct,  and  that  we  should  form  an 
erroneous  idea  of  the  diseases  which  I  am  now  about  to  consider, 
were  we  to  regard  any  of  them  as  a  mere  flux  of  humours,  and  not 
as  inflammatory  affections. 

The  pain  in  all  the  puro-mucous  ophthalmise  is  distinctive,  and 
is  compared  by  the  patient  to  the  feeling  excited  by  sand  in  the  eye. 

Puro-mucous  conjunctivitis,  as  I  have  already  mentioned,  at 
length  wears  itself  out,  and  subsides  ;  but  before  this  happens,  the 
eye  may  be  entirely  destroyed,  the  cornea  having  grown  opaque,  or 
having  become  infiltrated  with  pus,  ulcerated,  and  given  way. 


273 


SECTION  V. CATARRHAL    OPHTHALMIA.* 

There  are  three  ophthalmise,  which  are  frequently  excited,  es- 
pecially in  adults,  by  atmospheric  influences  ;  namely,  the  catarrhal, 
the  rheumatic,  and  the  catarrho-rheumatic.  The  first  of  these  is  a 
puro-mucous  or  blenorrhoeal  inflammation  of  the  conjunctiva  ;  the 
second  is  an  affection  of  the  fibrous  sclerotica ;  while  in  the  third, 
both  the  conjunctiva  and  sclerotica  are  attacked,  and  the  symptoms 
of  the  catarrhal  are  united  to  those  of  the  rheumatic  ophthalmia. 

Symptoms.  The  inflammation  in  the  catarrhal  ophthalmia, 
which  is  by  far  the  most  common  disease  of  the  eye  in  adults,  is 
ahnost  entirely  confined  to  the  conjunctiva  and  Meibomian  folHcles. 
The  mucous  secretion  of  the  membrane  is  increased  in  quantity, 
and  occasionally  becomes  opaque,  thick,  and  purifoim  ;  but  in 
many  cases  remains  transparent,  and  by  its  superabundant  quan- 
tity renders  the  eyelids  merely  more  than  usually  moist  and  sUp- 
pery ;  while  the  Meibomian  secretion,  also  increased  in  quantity 
and  changed  by  disease,  concretes  on  the  edges  of  the  lids  and 
amongst  the  eyelashes,  and  binds  them  together  during  the  night. 

In  mild  cases,  the  redness  is  chiefly  in  the  conjunctiva  lining  the 
eyelids.  On  the  white  of  the  eye,  the  vessels  are  arranged  in  a 
network ;  and  can  be  moved  in  every  direction,  by  pressing  the 
eyelid  against  the  eyeball  with  the  finger,  showing  that  they  reside 
in  the  conjunctiva.  Not  unfrequently  we  observe  spots  of  extrava- 
sated  blood  beneath  the"  conjunctiva.  In  severe  cases,  chemosis, 
takes  place,  even  to  a  great  extent ;  so  much  so,  that  if  only  gene- 
ral treatment  be  employed,  as  blood-letting  and  purging,  while  local 
means  are  neglected,  the  cornea  may  lose  its  vitality,  become  infil- 
trated with  pus,  burst,  and  slough,  and  thus  vision  be  destroyed.  I 
have  been  led  to  attribute  the  destruction  of  the  cornea  in  severe 
cases  of  catarrhal  ophthalmia,  as  also  in  the  contagious  or  Egyptian 
ophthalmia,  and  in  the  ophthalmia  of  newborn  children,  not  en- 
tirely to  a  vital,  but  partly  to  a  mechanical  cause ;  not  altogether  to 
excessive  inflammatory  action  in  the  cornea  itself,  but  partly  to  the 
pressure  caused  by  the  enormously  distended  conjunctiva  of  the 
eyelids  and  eyeball.  Other  causes,  no  doubt,  concur,  in  the  puro- 
mucous  inflammations  of  the  conjunctiva,  to  produce  opacities  of 
the  cornea,  detachment  of  its  conjunctival  covering,  and  ulceration ; 
and,  in  particular,  the  maceration  of  the  cornea  in  a  flood  of  puru- 
lent fluid,  not  sedulously  removed  by  injections.  But  the  destruc- 
tion of  the  cornea  by  infiltration  of  pus  and  sloughing,  I  am  dis- 
posed to  refer  in  no  small  degree  to  the  pressure  of  the  chemosed 
conjunctiva,  and  the  consequent  mechanical  death  of  the  cornea. 

Diagnosis.  In  the  catarrhal  ophthalmia,  the  patient  uniformly 
complains  of  a  feeling  of  roughness  of  the  eye,  of  sand,  hot  ashes, 
or  broken  glass  under  the  upper  eyelid  ;  a  sensation  which  never 

*  Conjunctivitis  Puro-mucosa  atmospherica. 

35 


274 

attends  the  pure  rheumatic  ophthahnia,  and  may  therefore  be  re- 
garded as  strikingly  diagnostic.  ^Jor^over.  in  the  catarrhal  ophthal- 
mia, the  patieLt  is  generally  free  from  hendach  ;  v.'hereas  in  the 
rheumatic,  one  of  the  most  remarkable  symptoms  is  supra-orbital  or 
circum-orbital  pain,  severely  aggravated  during  the  night.  When 
headach  does  attend  catarrhal  ophthalmia,  it  is  seated  across  the 
forehead,  and  is  felt  most  in  the  morning. 

So  distressing,  even  at  the  beginning  of  an  attack  of  catan-hal 
ophthalmia,  is  the  sensation  as  if  sand  or  some  other  foreign  body 
were  under  the  upper  eyelid,  that  I  have  repeatedly  been  requested 
to  visit  patients,  in  whom  this  disease  was  commencing,  who  sup- 
posed that  some  particle  of  dust  had  actually  got  into  that  situation  ; 
and  in  one  instance  I  was  called  to  visit  a  medical  gentleman,  who 
was  so  convinced,  from  the  feelings  which  he  experienced,  that  this 
was  the  case,  that  he  had  made  various  attempts,  with  his  dressing 
probe  to  free  himself  from  the  imaginary  ofifending  substance. 

Causes.  Atmospheric  changes,  and  especially  exposure  to  cold 
and  wet,  are  the  exciting  causes  of  this  disease.  Night- watching,  and 
exposure  to  the  night-air,  after  being  much  heated,  or  in  a  state  of 
intoxication,  are  frequently  the  occasions  which  give  rise  to  catarrh- 
al ophthalmia.  Wet  feet  is  a  cause  which  some  of  my  patients 
have  particularly  mentioned.  An  individual  who  has  once  labour- 
ed under  this  disease,  is  more  likely  to  be  attacked  again  :  one  of 
my  patients  had  three  attacks  between  ^lB.y  and  January. 

Epidemic,  In  many  instances  the  catarrhal  ophthalmia  has 
been  known  suddenly  to  attack  a  great  number  of  persons,  who 
happened  to  be  exposed  to  the  same  general  exciting  causes.  As- 
salini,  for  example,  relates,  tha,t  in  May,  1792,  several  battalions  of 
the  duke  of  Modena's  troops  arrived  at  Reggio,  in  order  to  quell 
some  riots.  These  troops  passed  the  first  night  after  their  arrival 
under  the  spacious  porticoes  of  a  convent  looking  to  the  north,  in 
the  lowest  part  of  the  town,  and  near  the  trenches  of  the  citadel. 
Many  of  these  soldiers  contracted  a  violent  catarrhal  ophthalmia, 
which  was  attributed  to  the  dust  of  the  straw  on  which  they  had 
slept ;  and  not  to  the  moist  and  cold  air  of  the  place,  which  no  doubt 
was  the  true  cause,  and  which  was  so  much  the  more  likely  to  prove 
hurtful,  as  these  men  had  been  accustomed  to  close  and  comfortable 
quarters.* 

The  catarrhal  ophihalmia  has  been  known  to  spread  itself  still 
more  extensively,  attacking  a  great  proportion  of  the  inhabitants  of 
a  town  or  district,  so  as  to  obtain  the  name  of  epidemic  ophthabnia. 
In  1778,  it  attacked  the  whole  neighbourhood  about  Newbury,  in 
Berkshire  :  and,  in  the  same  year,  it  prevailed  in  several  of  the 
English  caiTips,  where  it  was  known  by  the  name  of  the  ocular  dis- 
ease. In  1S06,  an  epidemic  ophthalmia  of  this  kind  prevailed  ia 
Paris,  and  was,  in  many  instances,  attended  by  an  affection  of  the 

•  Manuals  di  Chirurigia.     Parte  ii.  p.  117.     jNIilano,  1812. 


275 

mucous  membrane  of  the  air  passages  ;  a  complication  which  I  have 
repeatedly  observed  in  the  sporadic  cases  of  this  country.  The 
same  disease  prevailed  in  1808,  at  Vicenza,  in  Italy.  It  has  been 
mentioned  by  some  authors,  that  this  disease  is  more  common  in 
summer  and  autumn.  In  this  town  and  neighbourhood,  it  is  com- 
mon at  all  seasons. 

Prognosis.  If  the  catarrhal  ophthalmia  be  neglected,  or  treated 
only  with  general  remedies,  or  with  improper  local  ones,  it  wiii  con- 
tinue for  many  weeks,  and  become  the  cause  of  much  febrile  ex- 
citement and  constitutional  illness,  as  well  as  local  distress  and  dan- 
ger. Amongst  other  bad  effects  of  neglect,  the  conjunctiva,  particu- 
larly where  it  lines  the  upper  eyelid,  becomes  sarcomatous  and  rough, 
and  by  rubbing  in  this  state  against  the  cornea,  brings  on  a  vascu- 
lar and  nebulous  state,  or  it  may  be,  even  a  dense  white  opacity, 
especially  of  the  upper  half  of  the  cornea.  The  discharge  from  the 
conjunctiva  is  more  apt,  also,  under  neglect  or  improper  treatment, 
to  become  puriform,  and  to  assume  the  power  of  propagating  the 
disease  by  contact. 

Contagious.  I  regard  it  as  scarcely  admitting  of  doubt,  that 
the  discharge  in  catarrhal  ophthalmia,  especially  when  distinctly 
puriform,  if  conveyed  from  the  eyes  of  the  patient  to  those  of  others, 
by  the  fingers,  or  by  the  use  of  towels  and  the  like  in  common, 
will  excite  a  conjunctivitis  still  more  severe,  more  distinctly  puri- 
form, and  more  dangerous  in  its  effects  on  the  transparent  parts  of 
the  eye.  than  was  the  original  ophthalmia.  This  is  the  conclusion 
at  which  I  have  arrived,  from  the  observation  of  many  instances, 
in  which,  as  far  as  it  was  possible  to  come  to  the  facts,  this  disease, 
having  arisen  in  one  member  of  a  family  from  atmospheric  expo- 
sure, several  others  of  the  family  have  become  affected  without  any 
such  exposure  that  could  be  ascertained  ;  and  while,  in  the  first 
affected,  the  disease  was  comparatively  moderate,  and  scarcely  pu- 
riform, in  the  latter  the  symptoms  were  more  violent,  and  the  dis- 
charge thick,  abundant,  and  opaque. 

I  think  it  probable,  that  the  ophthalmia  which  attacked  the 
British  and  French  armies  in  Egypt  was  an  atmospheric  puro- 
mucous  conjunctivitis,  but  that  it  afterwards  degenerated  into  a 
contagious,  perhaps  infectious,  disease,  that  is  to  say,  that  it  was 
propagated  by  actual  contact  of  the  discharge,  and  perhaps  by  mi- 
asmata from  the  discharge  floating  through  the  air.  Nor  is  this 
idea  inconsistent  with  what  is  generally  admitted  regarding  conta- 
gious and  infectious  diseases.  If  we  admit  such  a  thing  as  conta- 
gion or  infection  at  all,  we  must  also  admit,  I  should  apprehend, 
that  diseases,  originally  excited  by  external  influences,  w^ere  propa- 
gated only  in  the  second  and  succeeding  instances,  by  their  conta- 
gious or  infectious  power. 

I  know  of  no  experiments  in  which  the  discharge  from  an  eye 
affected  with  simple  catarrhal  ophthalmia,  or  puro-mucous  conjunc- 
tivitis  arising  from  atmospheric  influence,  has  been  applied  to  a 


276 

sound  eye.  Dr.  Guillie's  experiments,  indeed,  may  have  been 
performed  with  matter  of  this  description.  He  took  the  puriform 
mucus  from  the  eyelids  of  some  children  affected  with  puro-mucous 
conjunctivitis,  in  the  hospital  for  sick  children  at  Paris,  and  intro- 
duced it  under  the  eyelids  of  four  blind  children  belonging  to  the 
institution  for  the  blind.  These  children  were  amaurotic,  but  the 
external  surface  of  their  eyes  was  healthy  and  entire.  In  all  four  a 
regular  puro-mucous  conjuctivitis  was  produced.* 

In  the  next  section,  I  shall  have  occasion  to  refer  to  one  or 
more  striking  instances  of  catarrhal  ophthalmia  spreading  by  con- 
tagion. 

Treatment.  The  catarrhal  ophthalmia  yields  readily  to  a  very 
simple  treatment,  chiefly  of  a  local  and  stimulating  kind.  I  was 
first  struck  with  the  truth  of  this  fact,  in  the  successful  manage- 
ment of  this  disease  by  Professor  Beer,  at  Yienna,  in  1817  ;  and  I 
was  confirmed  in  this  view,  by  an  attentive  consideration  of  the 
cases  detailed  in  an  excellent  Report  by  Mr.  Melin,  pubhshed  in 
the  London  Medical  and  Physical  Journal  for  September,  1824. 
The  results  of  my  own  practice,  both  in  private  and  at  the  Eye 
Infirmary,  some  account  of  which  I  submitted  to  the  profession  in 
1826,t  have  amply  borne  me  out  in  the  belief,  that  general  reme- 
dies in  this  disease  are  inferior  in  importance  to  local  ones  ;  that 
violent  general  remedies  are  absurd,  and  worse  than  useless ; 
and  that  a  local  stimulant  treatment  may  almost  entirely  be  relied 
on. 

1.  I  very  rarely  find  it  necessary  to  take  away  blood  in  catarrhal 
ophthalmia,  either  from  a  vein  or  by  leeches.  When  there  is  more 
than  usual  constitutional  irritation,  the  taking  away  of  from  twelve 
to  twenty  ounces  of  blood  from  the  arm,  will  no  doubt  prove  useful ; 
but  this  will  rarely  be  necessary  if  the  disease  has  not  been  neglected 
for  a  number  of  days,  or  mistreated. 

2.  Scarification  of  the  conjunctiva  of  the  eyelids  is  necessary 
only  in  cases  in  which  there  is  some  degree  of  chemosis,  and  a 
distinctly  puriform  discharge.  In  such  cases,  it  proves  a  valuable 
means  of  cure,  if  performed  according  to  the  directions  aheady  given 
at  page  267. 

3.  A  brisk  dose  of  calomel  and  jalap  may  be  ordered  at  the  com- 
mencement, with  occasional  doses  of  neutral  salts  during  the  course 
of  the  disease. 

4.  Determining  to  the  skin  is  also  usefid.  This  may  be  done 
by  the  warm  pediluvium  at  bedtime,  and  by  small  doses  of  spiritus 
Mindereri,  or  of  any  other  mild  diaphoretic,  in  combination  with 
diluent  drinks. 

5.  In  severe  cases,  a  blister  to  the  back  of  the  neck  will  be  found 
useful,  or  blisters  behind  the  ears,  kept  open. 

•  Bibliotheque  Ophthalmologique.     Tome  I.  p.  81.     Paris,  1820. 
t  Medical  and  Physical  Journal.    Vol.  Ivi.  p.  327.    London,  1826. 


277 

6.  Even  weak  solutions  of  acetate  of  lead,  or  of  sulphate  of 
zinc,  appear  to  be  prejudicial  in  this  disease,  aggravating  the  in- 
flammation, increasing  the  sensation  as  if  sand  were  in  the  eye, 
favouring  the  formation  of  ulcers  on  the  cornea,  or  if  ulcers  be  al- 
ready present,  leading  to  opaque  cicatrices. 

7.  On  the  contrary,  the  feeling  of  sand  is  uniformly  relieved,  and 
the  inflammation  abated,  by  the  use  of  a  solution  of  nitrate  of  silver. 
The  solution  which  I  employ  contains  from  two  to  four  grains  of 
the  nitrate  in  one  ounce  of  distilled  water.  A  large  drop  is  to  be 
applied  to  the  eye  once  a-day,  by  means  of  a  camel  hair  pencil. 
The  instant  that  it  touches  the  eye,  the  salt  is  decomposed,  and 
the  silver  precipitated  over  the  conjunctiva  in  the  state  of  muriate. 
I  have  sometimes  alarmed  other  practitioners,  by  proposing  to  drop 
upon  the  surface  of  an  eye  highly  vascular,  affected  with  a  feeling 
as  if  broken  pieces  of  glass  wei'e  rolling  under  the  eyelids,  and  ev- 
idently secreting  purulent  matter,  a  solution  of  lunar  caustic  ;  and 
I  have  been  not  a  little  pleased  and  amused  at  their  surprise,  when, 
next  day,  they  have  found  all  the  symptoms  much  abated  by  the 
use  of  this  application. 

8.  As  a  coUyrium,  I  am  in  the  habit  of  employing  a  solution  of 
one  grain  of  corrosive  sublimate  in  eight  ounces  of  water.  This 
being  made  milk-warm,  is  to  be  used  thrice  a  day  for  fomenting 
the  eyelids,  by  means  of  a  linen  rag.  In  mild  cases,  a  few  drops 
are  then  allowed  to  flow  in  upon  the  eye  ;  but,  in  severe  cases, 
in  which  the  discharge  is  copious  and  puriform,  this  coUyrium 
must  be  injected  over  the  whole  surface  of  the  conjunctiva,  and 
especially  into  the  upper  fold  of  that  membrane,  by  means  of  a 
syringe,  so  that  the  whole  morbid  secretion  may  be  removed,  and 
the  diseased  membrane  touched  immediately  by  the  solution. 

9.  At  bedtime,  about  the  size  of  a  hemp-seed  of  red  precipitate 
ointment,  melted  on  the  end  of  the  finger,  is  to  be  smeared  along 
the  edges  of  the  eyelids.  This  ointment  must  be  prepared  in  the 
manner  specified  at  page  114. 

10.  The  inside  of  the  lids,  and  especially  of  the  upper,  ought 
daily  to  be  inspected.  If  there  is  any  tendency  to  a  rough  and 
sarcomatous  state  of  the  conjunctiva,  it  ought  to  be  alternately 
scarified  or  leeched,  and  touched  with  the  solid  sulphate  of  copper  or 
nitrate  of  silver,  as  I  shall  explain  more  particularly  under  the 
head  oi  granular  conjunctiva. 

I  have  treated  many  hundred  cases  of  catarrhal  ophthalmia  ac- 
cording to  the  plan  above  detailed,  and  with  uniform  success.  In 
almost  no  case,  (indeed,  I  may  say  in  no  case  in  which  struma 
did  not  modify  the  symptoms),  in  which  the  above  simple  remedies 
were  had  recourse  to  previously  to  ulcer  or  opacity  of  the  cornea, 
did  any  ulcer  or  opacity  ever  occur  ;  nor  did  the  symptoms  ever 
fail  speedily  to  subside.  On  the  other  hand,  I  have  repeatedly  had 
occasion  to  see  cases  of  this  disease  which  had  been  much  aggra- 
vated by  trusting  altogether  to  general  treatment,  and  especially 


278 

to  bleeding  ;  or  by  the  use  of  acetate  of  lead,  or  sulphate  of  zinc, 
as  local  applications.  I  have  been  led  to  attribute  to  these  salts 
the  detachment  of  the  conjunctival  layer  of  the  cornea,  and  at  any 
rate  the  forn,atioa  of  opaque  cicatrices  ;  whereas,  superficial  ulcera- 
tions of  the  cornea,  treated  with  the  solution  of  nitrate  of  silver, 
have  uniformly  healed  without  opacity. 

Modified  hy  struma.  The  catarrhal  ophthalmia  occurring  in 
strumous  habits,  and  especially  in  children  of  that  constitution,  is 
very  liable  to  degenerate  into  the  phlyctenular  ophthalmia,  here- 
after to  be  described.  The  strumo-catarrhal  is  one  of  the  compound 
ophthalmiae,  which  are  apt  to  prove  puzzhng  to  the  inexperienced 
practitioner.  The  treatment,  in  cases  of  this  sort,  must  partake 
of  the  remedies  above  mentioned,  and  of  those  hereafter  to  be  re- 
commended for  strumous  conjunctivitis. 


SECTION   VI. CONTAGIOUS    OPHTHALMIA. 

This  disease  is  essentially  the  same  with  that  described  in  the 
last  section,  only  much  more  severe,  and  excited  in  a  different 
way,  namely,  by  contagion,  and  perhaps  by  infection.  It  is  a 
common  and  most  afflictive  disease  in  warm  climates,  as  Egypt, 
Persia,  and  India.  From  having  passed,  along  with  the  British 
troops  from  Egypt  to  this  country,  in  1800,  1801,  and  1802,  it  is 
often  spoken  of  under  the  name  of  the  Egyptian  ophthalmia. 

Symptoms.  These  succeed  each  other  with  different  degrees 
of  rapidity,  and  present  veiy  different  degrees  of  severity,  in  differ- 
ent individuals  w^ho  are  suffering  at  the  same  time,  in  the  same 
place,  and  from  the  same  infection.  These  differences  depend  on 
the  constitution  of  the  patients,  on  their  state  of  health  when  they 
become  affected,  and  upon  incidental  and  minute  circumstances  of 
situation.  In  w^omen,  for  instance,  the  disease  is  said  to  be  milder 
than  in  men.  It  has  also  been  remarked,  that  as  the  age  is  near 
to  puberty,  on  either  side,  the  disease  is  in  general  more  fatal  in  its 
effects.  In  scrofulous  persons,  it  is  always  tedious,  and  more  likely 
to  destroy  the  eye. 

This  disease  is  also  much  more  severe  in  one  instance  of  its  oc- 
currence than  in  another.  In  1806,  it  raged  with  greater  rapidity 
and  severity  in  the  54th  than  in  the  52d  regiment.  It  never  was 
so  severe  in  the  Mihtary  Asylum  at  Chelsea,  as  in  the  latter  regi- 
ment. It  appears  to  have  been  much  more  severe  in  the  Military 
Asylum  in  1809  than  in  1804.  These  differences  appear  to  be 
owing  to  the  climate  and  situation  where  the  disease  occurs,  the 
temperature,  the  season  of  the  year,  and  other  general  causes. 

The  purely  inflammatory  stage  of  this  disease,  though  often 
shorter  in  its  duration,  appears  never  to  surpass  thirty  hours.     At 

♦  Conjunctivitis  Puro  mucosa  contagiosa,  vel  Egyptiaca.  Ophthabio-blenorrhoea. 
Purulent  ophithalmia. 


279 

the  end  of  that  time,  purulent  matter  is  always  formed  by  some 
portion  of  the  conjunctiva.  In  most  cases,  the  purely  inflammatory 
stage  is  so  slight  and  rapid,  as  not  to  come  under  the  observation  of 
the  surgeon.  So  early  does  the  formation  of  purulent  matter  take 
place,  that  even  when  the  inflammation  has  extended  no  fartUer 
than  the  palpebral  conjunctiva,  pus  is  seen  on  everting  the  eyelids, 
although  its  quantity  is  not  yet  sufficient  to  be  observed  unless  this 
mode  of  examination  be  adopted. 

The  disease  appears  to  commence  soon  after  the  application  of 
the  contagious  or  infectious  matter  to  the  conjunctiva  ;  but  in  many 
cases  it  advances  to  the  secretion  of  purulent  matter,  before  the 
patient  is  aware  that  he  is  affected  with  any  inflammation.  It 
often  happens  that  he  makes  no  complaint  till  his  attention  is  ex- 
cited by  finding  his  eyelids  adhering  in  the  morning,  or  till  the 
sensation  of  some  extraneous  body  in  the  eye  has  become  distress- 
ing. A  sudden  attack  of  darting  pain  through  the  eyeball  or  in 
the  forehead,  is  sometimes  the  first  thing  which  attracts  his  atten- 
tion, while  in  other  cases,  the  disease  advances  till  there  is  such 
vascularity  of  the  conjunctiva  as  cannot  fail  to  be  observed  by 
others.  In  all  these  cases,  the  disease  has  unquestionably  existed 
for  some  time,  but  it  has  been  unobserved  by  the  patient  himself,  or 
if  observed,  concealed.  When  this  disease  breaks  out  in  a  family, 
or  in  any  larger  community  of  individuals,  those  first  attacked, 
ignorant  of  the  previous  existence  of  the  disease  in  others  from 
whom  they  might  receive  it,  and  ignorant  of  its  nature,  will  seldom 
demand  advice  till  urged  by  the  violence  of  the  symptoms.  When 
once  the  plan  is  adopted,  as  it  should  always  be,  of  daily  inspecting 
the  healthy  individuals  of  any  community  in  which  the  disease  is 
likely  to  appear,  it  will  be  the  fault  of  the  surgeon  if  he  ever  meets 
with  a  new  case  in  which  the  disease  is  so  far  advanced  as  to  be 
attended  with  any  other  symptom  than  an  increased  vascularity  of 
the  conjunctiva  of  the  eyelids. 

The  right  eye  is  more  frequently  attacked  by  this  disease  than 
the  left.  It  is  also,  in  general,  more  severely  affected,  and  the  sight 
of  it  is  more  frequently  lost.  In  some  instances  only  one  of  the 
eyes  takes  the  disease,  but,  commonly,  both  suffer  from  it,  although 
there  is  often  an  interval  of  several  days  before  the  second  becomes 
inflamed. 

When  the  symptoms  succeed  each  other  with  moderate  rapidity, 
the  following  is  the  order  in  which  they  arise. 

A  considerable  degree  of  itching  is  first  felt  in  the  evening,  or 
suddenly  there  arises  in  the  eye  the  feeling  as  if  a  particle  of  dust 
were  between  the  lids  and  the  eyeball.  This  is  succeeded  by  a 
sticking  together  of  the  lids,  principally  complained  of  by  the  pa- 
tient on  awaking  in  the  morning.  The  eyelids  appear  fuller  ex- 
ternally than  they  ought  to  do.  Their  internal  surface  is  inflamed, 
being  tumefied  and  highly  vascular  ;  and  the  semilunar  membrane 
and  caruncula  lachrymalis  considerably  enlarged  and  redder  than 


280 

ijisual.  The  swelling  of  these  parts  is  soft,  somewhat  elastic,  slip' 
pery,  and  easily  excited  to  bleed. 

We  have  here  all  the  symptoms  of  the  purely  inflammatory 
stage,  and  even  the  symptoms  of  commencing  suppuration.  The 
itching,  which  is  one  of  the  earliest  symptoms,  indicates  a  suppres- 
sion of  the  natural  mucous  secretion  of  the  conjunctiva  of  the  eye- 
lids, and  of  the  Meibomian  secretion.  Such  suppression  appears  to 
be  the  constant  and  earliest  effect  of  inflammation  upon  every  mu- 
cous membrane,  and  secreting  organ  of  the  body.  In  the  course  of 
a  few  hours,  a  thin  acrid  secretion  takes  place  from  the  conjunctiva. 
This  gives  the  slipperiness  to  the  internal  surface  of  the  e3^elids ; 
and  the  Meibomian  secretion  being  now  increased  above  its  usual 
quantity,  concretes  among  the  eyelashes,  and  causes  the  eyelids  to 
adhere  during  sleep.  The  sensation  of  sand  in  the  eye  is  owing 
merely  to  the  dilated  state  of  the  conjunctival  vessels. 

In  about  twenty-four  hours  after  the  first  symptoms  make  their 
appearance,  the  mucous  discharge  from  the  internal  surface  of  each 
eyelid  is  considerable  in  quantity.  It  is  still  thin,  but  somewhat 
viscid,  and  begins  to  be  opaque.  It  lodges  at  the  inner  angle  of 
the  eye.  On  everting  the  lids,  their  internal  surface  is  observed  to 
be  much  more  vascular  and  tumid.  There  is  also  epiphora  present, 
especially  when  the  patient  exposes  his  eye  to  a  current  of  air.  He 
complains  of  a  sensation  as  if  the  eye  were  full  of  sand,  but  seems 
to  experience  but  little  uneasiness  from  the  light.  Not  unfrequently, 
a  considerable  discharge  of  blood  takes  place  from  the  conjunctiva, 
after  which  the  swelling  of  the  membrane  diminishes  for  a  time. 
This  is  sometimes  repeated  several  times  before  the  profuse  puri- 
forra  discharge  sets  in.  It  does  not  appear  to  arise  from  the  rup- 
ture of  vessels,  but  rather  to  come  from  the  exhalents  of  the  con- 
junctiva, dilated  by  red  blood,  or  by  a  mixture  of  red  blood  with  the 
transparent  fluid  which  they  usually  carry. 

The  inflammation  now  extends  to  the  whole  internal  surface  of 
the  eyelids.  The  secretion  from  the  palpebral  conjunctiva  is  much 
augmented,  aud  becomes  more  distinctly  puriform,  being  yellowish 
and  thick.  In  many  cases  it  is  so  abundant,  that  on  the  patient 
opening  his  eyes,  the  matter  instantly  flows  over  the  cheeks.  It 
irritates  the  skin,  and  even  excoriates  it.  The  swelhng  of  the  con- 
junctiva of  the  lids,  and  especially  of  the  upper,  increases  with  the 
discharge  ;  partly  from  a  serous  effusion  immediately  under  the 
membrane,  partly  from  an  unnatural  and  inflammatory  develop- 
ment of  its  vascular  structure,  partly  from  a  similar  enlargement 
of  its  mucous  cryptee,  and  of  the  Meibomian  follicles,  giving  rise  to 
a  sarcomatous  appearance  of  the  internal  surface  of  the  eyelids. 

The  disease  may  not  proceed  farther  over  the  conjunctiva  but 
remain  in  the  state  descrilsed  for  weeks  or  even  months,  and  how- 
ever severe  it  may  appear  to  another  person,  give  but  little  un- 
easiness to  the  patient.  The  purulent  secretion  may  then  diminish^ 
and  recovery  gradually  take  place. 


281 

In  other  cases,  the  inflammation  spreads  rapidly  to  the  conjunc- 
tiva of  the  eyeball.  Its  vessels  are  distended  with  red  blood, 
forming  a  thick  net-work  over  the  sclerotica,  interspersed,  in  some 
instances,  with  small  spots  from  extravasation.  The  membrane 
itself  becomes  speedily  thickened,  and  a  serous  effusion  taking  place 
into  the  cellular  membrane  which  connects  it  to  the  sclerotica,  it  is 
raised,  so  as  to  form  a  pale-red  and  soft  elevation  or  chemosis.  In 
some  cases,  this  inflammatory  osdema  exists  only  at  particular 
spots,  though  the  vascularity  of  the  conjunctiva  is  considerable  and 
extends  even  to  the  cornea.  It  commonly  happens  that  the  che- 
mosis gradually  spreads  from  the  lids  over  the  surface  of  the  eye 
towards  the  cornea,  with  its  advancing  edge  accurately  defined, 
leaving  for  a  while  a  circle  round  the  cornea  which  is  gradually 
intruded  on  by  the  swelling,  till  closely  surrounded,  and  at  last 
completely  buried  and  overlapped,  scarcely  can  even  its  centre  be 
perceived.  This  chemosis  is  sometimes  so  great,  that  the  conjunc- 
tiva of  the  eyeball  protrudes  considerably  from  between  the  lids. 

The  chemosis  is  accompanied  by  redness  and  swelling  of  the 
skin  of  the  eyelids,  sometimes  extending  to  a  considerable  distance 
from  the  eye,  and  resembling  very  much  in  colour  and  general 
appearance  the  redness  and  swelling  which  surround  the  cow-pox 
pustule  between  the  9th  and  12th  day  after  inoculation.  This  swel- 
ling of  the  hds  is  often  as  sudden  in  its  appearance,  as  if  it  had 
been  owing  to  the  stinging  of  an  insect,  or  some  other  immediate 
irritation.  It  sometimes  continues  to  increase  almost  by  sensible 
degrees,  and  attains  its  utmost  height  in  a  few  hours ;  at  other 
times,  it  increases  gradually  during  several  days. 

The  sudden  swelUng  of  the  lids  renders  them  almost  quite  im- 
movable. It  also  occasions  at  first  a  degree  of  inversion,  from  the 
cartilages  not  yielding  with  facility ;  but  as  the  disease  advances, 
the  lids  become  everted.  This  happens  especially  to  the  lower,  but 
occasionally  to  the  upper  also.  The  sensations  produced  by  this 
enlargement  of  the  external  parts  of  the  eye  are  by  no  means 
severely  painful,  scarcely  surpassing  a  sense  of  stiffness  and  weight, 
along  with  a  feeling  of  uneasiness  occasioned  by  the  accumulation 
of  matter  secreted  by  the  conjunctiva.  The  sensation  of  gravel  in 
the  eye  is  now  less  troublesome.  If  light  be  excluded,  and  the 
eyes  kept  at  rest,  the  patient  does  not  complain  much  of  pain. 

After  the  conjunctiva  of  the  eyeball  takes  part  in  the  disease,  the 
flow  of  puriform  fluid  is  greatly  increased  ;  varying,  however,  from 
time  to  time,  in  quantity,  colour,  and  consistence,  as  does  the  dis- 
charge in  gonorrhoea.  Dr.  Vetch  estimates  its  quantity  as  exceed- 
ing several  ounces  in  the  day.  It  partly  escapes  from  between  the 
lids,  partly  lodges  in  their  folds,  and  in  the  pit  formed  over  the 
cornea  by  the  chemosed  conjunctiva.  In  this  last  situation,  the 
purulent  discharge  is  sometimes  allowed,  from  carelessness,  to  re- 
main so  long,  that  it  assumes  the  appearance  of  a  thick  membrane, 
so  that  one  unacquainted  with  the  symptoms,  on  seeing  this  piece 
36 


282 

of  matter  drop  from  the  eye,  is  apt  to  suppose  that  the  whole  orgaa 
is  destroj'ed.  and  that  it  is  the  cornea  itself  in  the  state  of  a  slough 
which  has  separated. 

The  puriform  secretion  may  continue  without  much  change  for 
twelve  or  fourteen  days,  or  even  a  longer  period.  The  swoln  con- 
junctiva of  the  eyeball,  in  the  meantime,  becomes  sarcomatous,  but 
never  to  the  same  extent  as  that  of  the  lids.  At  length  the  che- 
mosis  begins  to  shrink,  and  the  fluid  secreted  to  diminish  in  quan- 
tity, and  gradually  to  lose  the  characters  of  pus,  becoming  thin  and 
gleety.  The  internal  surface  of  the  eyelids,  the  semilunar  mem- 
brane, and  caruncula  lachrymalis,  which  were  the  parts  first  affected, 
are  the  last  in  which  the  disease  disappears.  Not  unfrequently 
the  internal  surface  of  the  lids  remains  in  a  sarcomatous  state^ 
seemingly  from  the  morbid  state  of  the  mucous  cryptee  of  the  con- 
junctiva, and  of  the  Meibomian  follicles.  These,  instead  of  sub- 
siding to  theh  natural  size,  become  indurated,  and  form  a  granular, 
scabrous,  or  mulberry  surface,  which  constantly  rubbing  against 
the  cornea,  keeps  up  a  chronic  inflammation  in  its  investing  mem- 
brane, which  becomes  covered  with  red  vessels,  and  loses  in  a  great 
measure  its  transparenc}*. 

Such  may  be  looked  upon  as  a  favourable  case  of  this  disease. 
We  must  be  prepared  to  meet  with  much  more  destructive  termi- 
nations of  it. 

In  some  cases,  the  primary  inflammation  extends  to  the  layer 
of  conjunctiva  which  covers  the  cornea.  That  layer  becomes- 
thickened,  detached  in  some  measure  from  the  cornea,  and  more  or 
less  opaque.  The  patient's  vision  is  much  diminished  by  these 
changes  ;  and  very  frequently  the  opacity  and  consequent  diminu- 
tion of  vision  continue  after  all  the  acute  symptoms  of  the  disease 
have  disappeared.  Superficial  ulceration  frequently  attacks  the 
cornea  in  the  course  of  this  disease,  giving  rise  to  opaque  cicatrices 
of  various  sizes,  and  often  producing  a  partial  flatness,  or  rendering 
the  cornea  irregular  on  its  surface,  and  permanently  unfit  for  dis- 
tinct vision.  Even  when  the  ulceration  has  not  penetrated  through 
the  corn3a,  the  iris  sometimes  advances  and  adheres  to  its  internal 
surface,  opposite  to  the  ulcerated  part. 

In  other  cases  the  inflammatory  process  is  still  more  severe,  at- 
tacking the  whole  substance  of  the  cornea,  and  even  extending  to 
the  internal  textures  of  the  eye.  The  patient  is  now  subject  to 
deep-seated  pulsative  pain  in  the  eye,  coming  on  sometimes  in  par- 
oxysms, in  other  instances  continuing  with  scarcely  any  remission 
in  its  violence  till  the  cornea  gives  way.  The  varieties,  indeed,  in 
regard  to  the  pain,  are  exceedingly^  remarkable,  depending  no 
doubt  in  a  considerable  measure  on  the  part  which  the  several  tex- 
tures of  the  e3'e  take  in  the  disease.  For  the  most  part,  the  attacks 
of  pain  are  sudden.  Occasionally  they  are  preceded  by  chillness 
and  slight  nausea,  or  by  a  peculiar  sensation  about  the  head.  Fre- 
quently the  pain,  with  a  remarkable  increase  of  heat,  occurs  around 


283 

the  orbit,  in  a  degree  no  less  excruciating-  than  in  the  eye  itself. 
The  space  over  the  frontal  sinuses,  the  temples,  and  the  face,  are 
its  frequent  seats,  or  to  speak  more  correctly  it  affects  the  branches 
of  the  fifth  pair  of  nerves,  distributed  to  these  parts.  Sometimes  it 
occurs  immediately  above  the  eye,  commencing  about  the  supra- 
orbitary  foramen.  This  supra-orbital  or  circum-orbital  pain  is  in- 
dicative of  the  inflammation  extending  to  the  sclerotica,  cornea, 
choroid,  and  iris.  Inflammation  of  these  textures  always  excites 
sympathetic  pain  in  the  fifth  pair  of  nerves.  The  pain  round  the 
eye  is  aggravated  by  pressure,  and  occasionally  a  circumscribed 
swelling  suddenly  takes  place  over  the  part  affected.  When  such 
a  swelling  appears  in  the  face,  it  partakes  of  an  oedematous  nature, 
and  though  equally  sudden  in  its  accession,  does  not  subside  so 
rapidly  during  an  intermission,  as  the  swellings  which  rise  under 
the  same  circumstances  on  the  forehead  and  temple.  At  all  times, 
the  eye  is  the  most  frequent  seat  of  the  pain.  It  is  described  to  be, 
in  the  eye,  of  a  darting  or  shooting  kind.  Sometimes  it  is  compared 
by  the  patient  to  what  might  be  felt  if  the  eye  were  stuck  full  of 
needles,  and  always  appears  to  be  of  almost  insufferable  severity. 
It  is  generally  confined  to  one  eye  at  a  time,  though  it  frequently 
shifts  from  the  one  to  the  other. 

The  apparent  absence  of  all  uneasiness  from  the  presence  of 
light,  during  the  paroxysms,  is  probably  owing  to  the  patient's  at- 
tention being  engrossed  by  the  violence  of  the  pain.  The  duration 
of  the  paroxysms,  and  their  recurrence,  do  not  observe  any  great 
regularity.  The  more  common  duration  appears  to  be  from  three 
to  four  hours.  Sometimes  they  do  not  continue  longer  than  two 
hours,  and  sometimes  they  extend  to  six.  They  appear  to  come 
on  most  frequently  from  10  to  12  in  the  evening.  During  the 
pain,  the  secretion  of  tears  is  more  copious,  and  the  purulent  dis- 
charge, on  the  contrary,  almost  uniformly  diminished. 

This  intermittent  type  of  the  pain  is  a  remarkable  circumstance, 
and  might  appear  inexplicable,  were  we  not  acquainted  with  the 
fact,  that  pain  in  and  round  the  eye,  aggravated  during  certain 
hours  of  the  night,  is  an  invariable  attendant  on  sclerotitis.  It  has 
already  been  mentioned,  that  in  many  cases  there  is  no  entire  in- 
termission, and  scarcely  any  remission  in  the  violence  of  the  pain. 
Dr.  Vetch  (to  whose  excellent  account  of  this  disease  I  am  indebted 
for  many  of  the  facts  stated  in  this  section)  tells  us,  that  in  those 
patients  who  were  of  a  habit  particularly  robust,  or  who  had  been 
exposed  to  some  strongly  exciting  causes,  or  who  were  of  a  shape 
favourable  to  a  determination  to  the  head,  there  was  no  entire  in- 
termission, and  scarcely  eve;  any  remission  in  the  violence  of  the 
pain.* 

It  is  only  when  the  disease  assumes  its  most  violent  form  that 
it  is  accompanied  by  the  frequent  occurrence  of  the  paroxysms  of 

*  Account  of  the  Ophthalmia  which  has  appeared  in  England  since  the  return  of 
the  British  Army  from  Egypt,  p.  117.    London,  1807. 


284 

pain  above  described,  and  under  these  circumstances  the  rupture 
of  the  cornea  frequently  takes  place,  an  event  which  is  almost 
always  followed  by  staphyloma  and  loss  of  sight.  The  period  at 
which  this  happens  varies  exceedingly  in  different  patients.  In 
some  the  daily  occurrence  of  these  paroxysms  has  continued  for  a 
number  of  weeks  before  rupture  of  the  cornea  is  produced.  In 
others,  this  is  effected  under  the  second  or  third  attack,  and  gives 
a  temporary  relief.  I  say  terti'porary,  for  even  this  melancholy 
event  does  not  afford  a  termination  to  the  disease,  and  often  scarcely 
checks  its  progress.  The  severe  pain  is  seldom  present  in  both 
eyes  at  the  same  time,  and  although  it  occasionally  happens  that 
the  attacks  of  pain  alternate  from  the  one  eye  to  the  other,  the  rup- 
ture of  the  one  is  generally  produced  before  the  severe  pain  affects 
the  other.  In  some  cases,  where  both  eyes  are  destroyed  by  rup- 
ture of  the  cornea,  the  patient  has  no  recurrence  of  the  pain  for 
some  time  after  the  rupture  of  the  first ;  while  in  other  cases,  the 
pain  almost  instantaneously  shifts  to  the  other  eye.  It  has  been 
known  that  while  the  second  eye  was  suffering  rupture  of  the 
cornea,  the  first  eye,  by  cicatrizing,  was  only  becoming  liable  to 
the  same  accident  again,  and  this  second  rupture  of  the  cornea  has 
been  preceded  by  as  much  pain  as  was  the  fij'st. 

Rupture  of  the  cornea  generally  happens  when  the  disease  is  at 
the  height  of  its  violence,  and  when  the  swelling  of  the  external 
parts  is  so  great,  as  to  prevent  an  examination  of  those  immediately 
concerned  in  this  event.  From  the  distinct  sensation,  however, 
which  the  accident  uniformly  communicates  to  the  patient,  accom- 
panied by  a  copious  discharge  of  hot  fluid,  we  seldom  remain 
ignorant  of  the  event  having  taken  place.  In  other  instances,  the 
swelling  of  the  conjunctiva  and  of  the  eyelids  is  not  so  great  as  to 
prevent  the  inspection  of  the  eye  at  the  time  of  its  rupture.  In 
these  cases,  the  progress  of  disorganization  may  be  observed.  The 
surface  of  the  cornea  is  seen  to  be  first  whitish,  and  then,  from 
matter  infiltrated  into  its  substance,  it  becomes  yellow.  Its  lamellae 
are,  no  doubt,  detached  by  this  infiltration  from  one  another.  It 
swells,  and  advances  gradually  out  of  the  pit  formed  around  it  by 
the  chemosed  conjunctiva.  Its  surface  becomes  ulcerated  in  one 
or  more  points.  The  ulcers  rapidly  deepen  and  spread,  and  at  last 
the  cornea  gives  way.  Through  the  opening,  or  openings,  thus 
formed,  we  may  sometimes  see  the  yet  clear  lens  lying  in  its  cap- 
sule. It  rarely  happens  that  there  is  any  formation  of  pus,  or  de- 
position of  coagulable  lymph  in  the  chambers  of  the  eye  in  this 
disease ;  and  hence,  when  the  cornea  is  destroyed,  the  internal 
parts  of  the  eye  appear  natural.  The  patient  is  sometimes  able 
even  to  see  objects  pretty  distinctly  after  the  cornea  has  given  way, 
and  is  apt  to  believe  his  eye  to  be  nearly  cured,  or  at  least  out  of 
danger.  The  iris  is  pushed  forwards  into  the  opening  or  openings 
of  the  cornea,  union  takes  place  between  the  iris  and  cornea,  and 
partial  or  total  staphyloma  is  the  result.     In  some  cases,  the  iris, 


285 

after  the  eye  recovers,  remains  protruding  at  different  points,  scarcely 
covered  by  any  pseudo-cornea,  but  presenting  a  number  of  dark- 
coloured  prominences,  like  the  grains  of  a  brambleberry,  a  state  of 
the  cornea  and  iris  which  is  styled  stapliylom,a  racemosum. 

In  some  cases  at  least,  it  would  appear  that  the  cornea  is  rup' 
tured  under  one  of  those  violent  paroxysms  of  pain  of  which  I  have 
spoken,  before  it  has  undergone  much  disorganization.  Dr.  Vetch 
minutely  describes  a  case,  in  which,  on  examining  the  eye  after 
the  patient  had  felt  the  peculiar  sensation  indicating  the  rupture 
of  the  cornea,  and  the  discharge  of  scalding  fluid  had  taken  place 
which  attends  this  accident,  he  found  merely  a  small  hne  extending 
across  the  lower  segment  of  the  cornea,  and  which  remained  with- 
out any  alteration  after  the  eye  was  washed  with  tepid  water.  As 
any  attempts  to  ascertain  the  nature  of  this  line,  gave  uneasiness, 
its  examination  was  left  to  next  day.  In  the  meantime,  the  patient 
saw  better  than  he  had  done  before  the  rupture  took  place.  Next 
day,  the  line  was  more  visible  along  its  whole  extent,  from  a  shght 
opacity  which  accompanied  it,  and  which  daily  increased,  till  the 
greater  part  of  the  cornea  was  not  only  opaque,  but  projected  in  an 
irregular  cone,  and  as  this  alteration  went  on,  vision,  which  for 
some  time  after  the  rupture  continued  more  correct  than  before, 
became  totally  obstructed. 

It  would  thus  appear  that  in  certain  cases,  the  aqueous  humour 
escapes  by  a  division  of  the  cornea,  nearly  as  <:lean  as  if  made  with 
a  knife.  Were  the  disease  to  subside  immediately  after  such  a 
rupture  of  the  cornea,  this  accident  would  in  all  likelihood  be  at- 
tended with  little  permanent  injury  to  the  sight.  But,  besides  the 
obstacles  which  the  presence  of  the  disease  occasions  to  the  healthy 
reunion  of  the  cornea,  the  same  causes  which  produced  the  first 
rupture  continue  to  operate,  so  as  to  produce  a  second  or  a  third, 
the  disorganization  and  deformity  increase,  and  the  termination 
with  respect  to  vision  is  proportionably  unfavourable. 

As  Dr.  Vetch  relates  one  case  of  this  kind  of  rupture  of  the  cor- 
nea with  much  minuteness,  and  tells  us  that  he  has  seen  several 
others  of  the  same  kind,  I  cannot  think  that  he  has  been  mistaken 
concerning  the  fact.  Yet  I  am  convinced  that  this  kind  of  rupture, 
far  from  being  the  manner  in  which  th«  cornea  generally  gives 
way,  occurs  but  very  rarely.  Ulceration,  commencing  on  the  sur- 
face, and  gradually  penetrating  into  the  cornea,  is  one  mode  in 
which  this  important  part  is  destroyed  ;  infiltration  of  matter  into 
its  substance,  presenting  at  first  the  appearance  denominated  onyx, 
and  at  length  forming  complete  abscess  of  the  cornea,  followed  by 
rupture  and  ulceration,  is  another,  and,  I  believe,  the  most  fre- 
quent. 

In  many  cases,  the  progress  of  the  disease  does  not  cease  with 
the  bursting  of  the  cornea.  In  a  few  hours,  ulceration  attacks  the 
capsule  of  the  lens,  the  capsule  bursts  as  the  cornea  formerly  did, 
the  lens  escapes  through  the  ruptured  capsule  and  cornea,  more  or 


286 

less  of  the  vitreous  humour  generally  follows,  and  sometimes  almost 
the  whole  contents  of  the  eyeball  are  evacuated.  In  this  case,  a 
small  deformed  eyeball  is  left  deep  sunk  in  the  orbit,  over  which 
the  lids  fall  in,  become  concave  externally,  and  remain  ever  after- 
wards closed. 

Although  this  ophthalmia  proves  most  contagious  in  warm 
weather,  it  is  greatly  aggravated  by  the  patients  exposure  to  cold 
and  moisture.  The  symptoms  are  also  more  severe  in  females  for 
some  days  previous  to  menstruation,  and  on  this  evacuation  taking 
place  they  are  as  constantly  veiy  much  lessened. 

The  external  symptoms  of  this  disease,  and  the  pain  by  which 
it  is  attended,  cease  at  very  uncertain  periods.  After  the  severe 
pain  has  entirely  subsided,  the  vascularity  and  sarcomatous  tumefac- 
tion of  the  conjunctiva  generally  remain  stationary  for  a  considerable 
length  of  time,  and  then  rapidly  diminish.  In  others,  this  process 
goes  on  slowly  and  gradually.  The  external  tumefaction  of  the 
eyelids  commonly  disappears  first,  and  then  the  chemosis  gradually 
subsides,  that  part  of  the  conjunctiva  which  immediately  surrounds 
the  cornea  first  assumingits  natural  appearance,  and  presentingaring 
of  white  similar  to  what  was  formerly  seen  in  the  advancement  of 
the  disease.  The  white  space  graduall}'^  enlarges  till  the  swelling  and 
vascularity  are  confined  to  the  semilunar  membrane  and  its  neigh- 
bourhood, and  to  the  bottom  of  the  folds  between  the  eyeball  and 
eyelids.  The  eyelids  have  now  a  gaping  and  relaxed  appearance 
from  the  subsidence  of  the  tumefaction,  and  a  little  matter  still 
forms  on  their  internal  surface.  In  this  state,  which  may  continue 
for  months,  any  irritation  of  the  eye  or  of  the  system  is  sufficient  to 
cause  a  relapse  as  violent  as  the  original  attack,  and  the  patient 
still  continues  capable  of  infecting  others. 

The  rapidity  with  which  the  opacities  of  the  cornea  caused  by 
this  disease  frequently  disappear,  when  their  removal  once  begins 
to  take  place,  is  a  remarkable  circumstance.  In  many  cases  of 
opacity  of  the  cornea,  which  had  been  supposed  to  be  perfectly  hope- 
less, the  patients  have  speedily  recovered  such  a  degree  of  vision  as 
to  be  of  considerable  use  to  them.  Dr.  Vetch  relates  a  very  remark- 
able illustration  of  this  fact.  During  the  convalescence  of  a  man 
from  this  disease,  some  pectoral  symptoms,  to  which  he  had  long 
been  subject,  suddenly  assumed  the  appearance  of  pulmonary  con- 
sumption, which  proceeded  rapidly  towards  its  last  stage.  Five 
days  before  his  death,  he  was  seized  with  a  violent  aggravation  of 
the  hectic  fever  and  other  symptoms,  so  that  his  death  was  hourly 
expected.  At  this  time,  to  the  surprise  of  his  attendants,  the  opaci- 
ties, by  which  the  vision  of  both  eyes  had  long  been  obstructed, 
disappeared  with  amazing  rapidity,  so  that  a  short  time  before  his 
death,  his  sight  became  nearly  as  distinct  as  ever.  On  examining 
his  eyes  after  death,  the  remains  of  the  opacity  were  found  to  extend 
to  the  internal  surface  of  the  cornea,  which  was  at  the  opaque  part 
slightly  corrugated.     There  was  also  a  very  partial  adhesion  of  the 


287 

iris  to  the  cornea  in  both  eyes,  which  had  not  been  discerned 
during  hfe. 

In  many  cases,  and  especially  in  those  who  have  suffered  re- 
peated relapses,  the  symptoms  which  are  the  latest  to  disappear  are 
the  enlarged  and  indurated  state  of  the  mucous  cryptse  of  the  con- 
junctiva of  the  eyelids,  and  of  the  Meibomian  follicles,  and  the  vas- 
cular and  nebulous  state  of  the  cornea  depending  on  the  constant 
irritation  produced  by  the  friction  of  the  diseased  eyelids  upon  the 
eyeball. 

The  state  of  the  conjunctiva  of  which  I  am  speaking  has  gene- 
rally received  the  name  of  Granular  Conjunctiva.  If  by  granu- 
lar, those  who  employed  this  term  meant  merely  that  the  conjunc- 
tiva was  extremely  irregular  on  its  surface,  the  name  would  not  be 
unexpressive  nor  very  improper.  It  has  evidently  been  used,  how- 
ever, to  signify  a  state  of  granulation.  We  have  even  heard  of 
removing  the  granulations  of  the  conjunctiva.  That  the  promi- 
nences in  question  are  not  granulations  is  proved  both  from  the 
nature  of  the  conjunctiva  and  from  the  history  of  this  symptom  itself. 
No  mucous  membrane  is  known  to  throw  out  granulations,  without 
having  been  previously  ulcerated  upon  its  surface.  But  in  this  dis- 
ease, no  ulceration  of  those  parts  of  the  conjunctiva  which  are 
affected  with  this  granular  appearance  has  ever  existed.  If  these 
prominences  were  really  granulations,  adhesion  between  the  eyelids 
and  the  eyeball  would  be  extremely  frequent,  whereas  this  is  a  very 
rare  occurrence,  and  so  far  as  I  have  observed  never  takes  place, 
without  a  previous  and  distinct  ulcer  either  of  the  cornea,  of  the 
conjunctiva  of  the  eyelids,  or  of  that  of  the  eyeball.  The  granular 
prominences  in  question  appear  to  be  principally  the  acini  of  the 
Meibomian  glands  in  a  state  of  enlargement. 

It  is  a  fact  particularly  worthy  of  notice,  that  a  patient  may  re- 
main for  many  months  with  the  conjunctiva  of  the  eyelids  in  the 
granular  state,  his  cornea  probably  vascular  and  nebulous,  but 
without  any  puriform  discharge,  and  after  a  fit  of  intoxication  or 
some  other  irregularity,  the  inflammation  shall  suddenly  return  in 
its  original  form,  and  with  its  original  propagative  power.  Hence 
it  may  happen  that  a  soldier,  discharged  in  the  state  described,  re- 
turning home  into  the  country,  and  there  from  intoxication  becom- 
ing affected  with  a  relapse,  may  give  rise  to  an  ophthalmia  which 
shall  spread  through  many  families,  and  present  all  the  symptoms 
and  the  severity  of  the  true  Egyptian  disease. 

Constitutional  symptoms.  The  system  does  not  appear  to  be 
in  the  smallest  degree  primarily  atFected  in  this  disease  ;  the  early 
stage  is  entirely  local.  But  as  the  local  symptoms  grow  in  severity, 
the  constitution  begins  to  suffer.  The  pulse  becomes  frequent,  and 
sometimes  sharp  ;  but  commonly  continues  soft.  The  skin  is  sel- 
dom hot.  The  tongue  is  white,  but  rarely  furred.  Thirst  is  sel- 
dom remarked.  The  appetite  for  food  is  rather  keen  than  other- 
wise.    The  bowels  are  slow.     The  blood  drawn  is  not,  in  general, 


288 

buffy.  All  these  circumstances  denote  how  little  the  constitution 
participates  in  the  early  stage  of  the  disease.  Varieties,  no  doubt^ 
must  occur  in  this  respect.  Judging  from  the  accounts  given  by 
Dr.  Vetch  and  Sir  Patrick  Macgregor,  we  should  conclude,  that 
children  labouring  under  this  disease  are  subject  to  more  constitu- 
tional irritation  than  adults.  At  last,  however,  there  is  always 
much  general  uneasiness,  and  sleep  is  prevented  by  the  paroxysms 
of  nocturnal  pain.  Great  debility  comes  on,  especially  when  the 
patient  has  suffered  repeated  relapses.  Sir  James  M'Gregor  states 
that  in  Egypt  the  disease  very  often"continued  two  or  three  months, 
that  it  much  impaired  the  general  health,  that  it  often  terminated  in 
diarrhoea  or  dysentery,  and  that  sometimes  the  patients  became 
hectic* 

Causes — Propagation  of  the  disease  from  person  to  person. 
I  have  already  explained  my  views  regarding  the  propagative 
power  assumed  by  the  common  catarrhal  conjunctivitis  of  this 
country ;  and  have  hinted  that  probably  the  ophthalmia  which 
arose  in  the  British  and  French  armies  in  Egypt,  and  with  which 
they  returned  to  Europe,  had  a  similar  oiigin.  Assalini  attributes 
the  disease  as  it  occurred  among  the  French,  to  the  vivid  light  and 
excessive  heat  of  the  country  as  predisposing  causes,  and  suppressed 
perspiration  as  the  occasional  cause ;  or,  in  other  words,  considers 
it  as  a  catarrhal  ophthalmia.  This  inflammation  of  the  conjunc- 
tiva, arising  where  or  how  it  may,  appears  speedily  to  acquire, 
if  it  does  not  from  the  first  possess  the  power  of  producing  by 
contagion  a  disease  similar  in  nature  to  itself,  but  much  more  se- 
vere. 

It  is  undeniable  that  the  return  of  the  Egyptian  expedition  intro- 
duced a  severe  contagious  ophthalmia  into  this  country,  which  af- 
terwards prevailed  extensively  in  regiments  which  had  never  served 
in  Egypt,  and  which  accompanied  the  British  troops  to  almost  every 
foreign  station  to  which  they  were  sent.  For  many  ages  this  oph- 
thalmia has  prevailed  in  Egypt.  It  is  more  frequent  among  the 
natives  of  the  country  than  among  strangers,  owing  to  the  freer 
intercourse  of  the  former  with  each  other ;  and  for  the  same  reason  it 
is  more  common  among  the  lower  than  the  higher  classes  of  society, 
and  more  in  cities  than  in  the  country.  But  it  does  not  take  its 
origin  in  Egypt  alone,  or  other  warm  countries.  It  has  been  known 
to  arise  among  a  ship's  crew,  far  from  land.  It  is  only  the  coldness 
of  this  climate,  and  our  attention  to  cleanliness,  which  prevent 
the  common  catarrhal  ophthalmia,  which  we  see  every  day,, 
from  degenerating  into  the  contagious  disease  of  the  same  kind. 

Whether  this  disease  be  capable  of  propagating  itself  by  infection,, 
that  is  to  say,  whether  the  mere  miasmata  arising  from  the  eyes  of 
those  affected  with  it,  floating  through  the  air,  be  capable  of  excit- 
ing the  same  disease  in  the  eyes  of  others,  is  a  point  which  still  re- 

*  Medical  Sketches   of  the  Expedition  to  Egypt  from  India,  p.  151.     London, 
1804. 


289 

mains  in  doubt ;  for  in  every  case  in  which  this  ophthalmia  has 
spread  through  a  regiment,  a  school,  or  a  family,  there  has  been  a 
suspicion  of  actual  contact,  by  means  either  of  the  fingers  of  the 
patients,  or  of  the  towels  or  other  utensils  which  they  were  in  the 
habit  of  using  in  common.  Speaking  of  soldiers,  Dr.  Yetch  says, 
"  Each  company  has  a  separate  room,  in  which  the  intercourse 
among  the  men  is  necessarily  great.  Many  things  are  used  in 
common  ;  nor  are  they  even  over-scrupulous  in  washing  their  faces 
in  the  same  water  ;  and  however  attentively  some  may  avoid  this, 
they  are  all  under  the  necessity  of  having  recourse  to  the  same 
towel."  The  same  author  observes,  that  "  all  the  attendants  on  the 
sick,  who  were  particularly  careful  in  avoiding  such  intercourse  as 
might  communicate  a  local  disease,  escaped  without  exception," 

The  experiments  of  Dr.  Guillie,  to  which  I  have  referred  at  page 
276,  fully  demonstrate  that  this  disease,  is,  in  the  strict  sense  of  the 
term,  contagious,  in  other  words,  that  the  matter  taken  from  an  eye 
affected  with  this  ophthalmia,  and  applied  to  the  healthy  conjunc- 
tiva of  another  eye,  will  produce  the  same  disease. 

Sir  Patrick  Macgregor  has  recorded  several  interesting  cases  of 
accidental  inoculation  with  the  matter  from  the  conjunctiva  in  this 
disease. 

In  one  of  these,  a  nurse  of  the  Military  Asylum  Hospital,  about 
nine  o'clock,  a.  m.  when  occupied  in  syringing  the  e)'es  of  a  patient, 
who  had  much  swelhng  of  both  eyelids,  with  a  profuse  purulent 
discharge,  found  that  some  of  the  matter  mixed  with  the  injection 
had  spurted  into  her  left  eye.  She  was  directed  to  bathe  her  eye 
immediately  with  luke-warm  water.  She  did  so  for  several  min- 
utes ;  but,  notwithstanding  this  precaution,  about  seven  o'clock  in 
the  evening,  the  left  eye  began  to  itch  to  such  a  degree,  that  she 
could  not  refrain  from  rubbing  it.  When  she  awoke  next  morning, 
the  eye  was  considerably  inflamed,  the  lids  were  swelled,  and  when 
she  moved  the  eyeball,  she  had  a  sensation  as  if  sand  was  lodged 
between  it  and  the  eyelids.  In  the  course  of  the  day,  purulent  mat- 
ter issued  from  the  eye,  and  other  symptoms  followed,  which  were 
similar  to  those  in  the  children  under  her  care.  The  disorder,  how- 
ever, subsided  under  the  usual  treatment  in  fourteen  days,  the  right 
eye  remaining  sound  during  the  progress  of  the  disease  in  the  left. 

Another  nurse,  about  eight  o'clock,  a.  m.  while  washing  with 
warm  water  the  eyes  of  a  boy  suffering  severely  frem  purulent 
ophthalmia,  inadvertently  applied  the  sponge  which  she  had  used 
to  her  right  eye.  She  immediately  mentioned  this  circumstance  to 
the  other  nurses,  but  took  no  means  to  prevent  infection.  Between 
three  and  four,  p.  m.  of  the  same  day,  great  itching  of  the  right  eye 
took  place,  and  before  she  went  to  bed,  it  was  considerably  inflamed. 
Next  morning  her  eyelids  were  swoln,  she  complained  of  pain  on 
moving  them,  and  the  whole  anterior  surface  of  the  eyeball  was 
much  inflamed.  A  purulent  discharge  also  began  to  trickle  down 
the  cheeks  from  the  inner  canthus.  The  symptoms  increased  in 
37 


290 

severity,  an-'^.  notwithstanding  the  means  thai  were  used  for  her 
relief,  the  eyeball  burst  in  front  of  the  pupil,  on  the  fourth  day  after 
the  application  of  the  purulent  matter.  The  sight  of  the  eye  was 
irrecoverably  lost,  and  the  inflammation  continued  for  upwards  of 
three  months  ;  but  the  left  eye  did  not  become  affected,* 

The  following  I  regard  as  a  striking,  and  indeed  fearful  in- 
stance of  puro-mucous  conjunctivitis,  excited  by  atmospheric  influ- 
ence, spreading  by  contagion. 

The  French  slave-ship  Rodeur,  Captain  B ,  of  200  tons  bur- 
den, left  Havre  on  the  24th  of  January,  1819,  for  the  coast  of 
Africa,  reached  her  destination  on  the  i4th  of  March,  and  cast  an- 
chor off  Bonny.  The  crew  of  22  men.  enjoyed  good  health  the 
whole  voyage,  and  during  their  stay  at  Bonny  till  the  6th  of  April. 
No  trace  of  ophthalmia  had  been  observed  among  the  inhabitants 
of  the  coast,  and  it  was  not  till  1.5  days  after  the  Rodeur  had  put  to 
sea,  and  was  nearly  on  the  equator,  that  the  first  symptoms  of  this 
frightful  disease  were  perceived. 

It  was  observed  that  the  negroes,  who  w^ere  160  in  number,  and 
crowded  together  in  the  hold,  and  between  decks,  had  contracted  a 
considerable  redness  of  the  eyes,  \v'hich  soread  with  rapidity  from 
one  to  another.  At  first,  however,  the  crew  paid  nogier.t  attention 
to  ihis  apoearance,  imngining  that  it  was  occasioned  merely  by  want 
of  fresh  tur  in  the  hold,  and  by  the  scarcity  of  water  ;  for  they  al- 
ready limited  the  allowance  of  water  to  iight  ounces  a-day,  and 
some  time  ufter  they  could  allow  only  half  a  glass  a-day.  it  was 
thought  sufficient  to  make  use  of  an  eye-water  made  from  an  infu- 
sion of  elder  flowers,  and,  following  the  advice  of  the  person  who 
acted  as  ship-surgeon,  to  bring  up  the  negroes  in  turns  upon  deck. 
This  salutary  measure,  however,  they  v;e.e  obliged  to  abandon; 
for  the  poor  Africans,  torn  from  their  LaLive  home,  and  heart-v;rung 
by  the  horrors  of  th^ir  situation,  as  well  as  by  the  recollections  of 
their  lest  freedom,  c  nbracing  each  other,  threw  themselves  into  the 
sea. 

The  disease,  which  had  spread  amongst  the  negroes  in  a  fright- 
ful and  rapid  manner,  now  began  to  threaten  even  the  crew.  The 
first  man  of  the  crew  attacked  was  a  sailor  who  slepc  under  deck, 
close  to  the  grated  partition  which  communicated  with  the  hold. 
Next  day,  a  lad  was  affected  with  the  ophthalmia ;  and,  in  the 
course  of  the  nest  three  days,  the  captaiii,  and  almost  all  the  crew, 
were  seized. 

In  the  morning,  on  awaking,  the  patients  experienced  a  shght 
prickling  and  itching  in  the  edges  of  the  eyelids,  which  became  red 
and  swoln.  Next  da}',  the  sweUing  of  the  eyelids  was  increased, 
and  attended  with  sharp  pain  ;  in  order  to  lessen  which,  they  ap- 
plied to  the  eyes  poultices  of  rice,  as  hot  as  they  could  bear  them. 
On  the  tliird  day  of  the  disease,  a  discharge  of  yellowish  matter 

*  Transactions  of  a  Society  for  the  Improvement  of  Medical  and  Chirurgical 
Knowledge,  Vol.  iii.  p.  52.     London,  1812. 


I 


291 

took  place,  rather  thin  at  first,  but  which  afterwards  became  viscid 
and  greenish  ;  and  was  so  abundant,  that  the  pa'ients  had  only 
to  open  their  eyes  every  quarter  of  an  hour,  when  the  matter  fell 
in  drops.  From  the  commencement  of  the  disease,  tiiere  v.-eie 
considerable  intolerance  of  light,  and  discharge  of  tears.  When 
the  rice  failed,  bciled  vermicelli  was  used  for  poult'ces  On  the 
fifth  day,  blisters  were  applied  to  the  nape  of  the  neck  of  some  of 
the  patients  ;  but,  as  the  canthaiides  were  soon  exhausted,  luey 
endeavored  to  supply  their  place  by  the  use  of  pediiuvia  containing 
mustard,  and  by  exposing'  the  swoln  eyelids  to  the  steam  of  hot 
v/ater. 

Far  from  diminishing  under  this  treatment,  the  pain  increased 
from  day  to  day,  as  well  as  the  number  of  those  who  lost  their 
sight ;  so  that  the  crew,  besides  fearing  a  revolt  among  the  negroes, 
were  struck  with  terror  lest  they  should  not  be  able  to  manage  the 
vessel  till  they  should  reach  the  Carribbee  Islands.  One  sailor 
only  had  escaped  the  contagion,  and  upon  him  their  whole  hopes 
depended.  The  Rodeur  had  already  fallen  in  with  a  Spanish 
ship,  the  Leon,  whose  whole  crew  were  so  atfected  with  the  same 
disease,  that  they  could  no  longer  manage  their  ship,  but  begged 
the  aid  of  the  Rodeur,  already  almost  as  helpless  as  themselves. 
The  seamen  of  the  Rodeur,  however,  could  not  abandon  their  own 
ship,  on  account  of  the  negroes  ;  nor  had  they  room  to  receive  the 
crew  of  the  Leon.  The  difficulty  of  nursing  so  many  patients  in  so 
narrow  lc  space,  and  the  want  of  fresh  provisions  and  of  medicines, 
made  the  survivors  envious  of  those  who  died  :  a  fate  which  teemed 
to  be  fast  coming  upon  all,  and  the  thought  of  which  c?  sed  gen- 
eral consternation. 

Some  of  the  sailors  made  use  of  brandy,  which  they  dropped  be- 
tween their  eyelids,  and  from  which  they  experienced  some  relief; 
which  might  have  suggested  to  the  surgeon  the  propriet}^  of  a  local 
stimulating  treatment. 

On  ihe  twelfth  day,  the  sailors  who  had  experienced  some  relief 
came  upon  deck  to  relieve  the  others.  Some  were  thrice  attacked 
with  the  disease. 

The  tumefaction  of  the  eyelids  having  subsided,  some  phlycte- 
Dulae  were  observed  on  the  conjunctiva  of  the  eyeball.  These 
the  surgeon  had  the  imprudence  to  open :  a  step  which  proved 
hurtful  in  his  own  case,  for  he  remained  blind,  without  any  possi- 
bility of  recovering  his  sight. 

On  reaching  Guadaloupe,  on  the  21st.  June,  the  crew  was  in  a 
de-^lorable  state  ;  but.  very  soon  after,  from  the  use  of  fresh  pro- 
visions, and  by  simple  lotions  of  spring  water  and  lemon  juice,  re- 
commended by  a  negress,  they  became  sensibly  better.  Three 
days  after  coming  ashore,  the  only  man  who,  during  the  voyage, 
had  escaped  the  contagion,  was  in  his  turn  seized  vith  the  same 
s}' mptoras :  the  ophthalmia  running  its  course  as  it  had  done  on 
board  ship. 


292 

Of  the  negroes,  thirty-nine  remained  totally  bhnd,  twelve  lost 
each  one  eye,  and  fourteen  had  specks,  more  or  less  considerable, 
of  the  cornea. 

Of  the  crew,  twelve  men  lost  their  sight ;  one  of  these  was  the 
surgeon.  Five  lost  each  one  eye,  and  amongst  these  was  the  cap- 
tain. Four  had  considerable  specks,  and  adhesions  of  the  iris  to 
the  cornea.* 

The  history  given  by  Sir  Patrick  Macgregor  of  tlie  spread  of 
puro-mucous  ophthalmia  in  the  Mihtary  Asylum  at  Chelsea,  (an 
extensive  institution  for  the  education  of  soldiers'  children,)  in  1804, 
appears  sufficiently  demonstrative  of  its  being  propagated  from 
person  to  person. 

"  In  the  beginning  of  the  month  of  April,  1804,"  says  he,  "  two 
boys,  brothers,  were  brought  to  the  Infirmary  with  their  eyes  in- 
flamed, but  in  so  shght  a  degree,  as  not  to  require  their  being  ad- 
mitted. They  were  made  out-patients,  and  by  using  the  common 
remedies,  got  well  in  eight  or  ten  days.  In  the  end  of  this  month, 
six  boys  with  ophthalmia  were  brought  to  me ;  three  of  them  had 
it  in  a  violent  degree,  and  were  admitted  into  the  Infirmary ;  the 
other  three  were  ordered  to  attend  daily  for  advice. 

"  In  the  month  of  May,  no  less  than  forty-four  boys,  and  five 
girls,  affected  with  ophthalmia,  were  brought  to  the  Infirmary. 
The  worst  cases  were  admitted ;  but  there  was  not  room  for  all, 
and  even  some  of  those  that  were  admitted,  were  necessarily  mixed 
with  other  sick. 

"  On  the  morning  of  the  fourth  day  after  their  admission,  two 
boys  who  were  in  the  same  ward,  labouring  under  other  com- 
plaints, were  attacked  with  inflammation  of  the  eyes,  and  in  the 
course  of  that  week  the  nurse  took  the  disease.  She  had  it  so 
violently,  as  to  be  deprived  of  sight  for  several  days,  and  rendered 
unable  to  do  the  duty  of  her  situation  for  about  three  weeks. 
About  the  same  time,  her  son,  a  boy  twelve  years  old,  who  had 
been  in  attendance  on  the  sick,  and  a  few  days  after,  her  two 
younger  children,  were  attacked,  as  were  several  of  the  sick  in  the 
same  ward. 

"  In  June,  fifty-eight  boys  and  thirty-two  girls  were  'attacked. 
It  was  in  general  observed,  that  they  had  the  disease  in  a  more 
violent  degree,  than  those  attacked  in  May.  In  the  course  of  this 
month,  the  nurse  of  the  Girls'  Hospital  caught  it,  and  her  husband, 
an  in-pensioner  of  Chelsea  Hospital,  who  came  daily  to  see  her, 
was  also  seized  with  it,  as  likewise  were  two  occasional  nurses. 
Upon  inquiry,  I  found,  that  the  above-mentioned  pensioner  was 
the  only  person  at  this  time  affected  with  ophthalmia  in  Chelsea 
Hospital. 

"  The  wife  of  a  field-officer  was  at  this  time  on  a  visit  at  the 
Military  Asylum.     She  had  a  son  between  five  and  six  years  of 

•  Bibliotheque  Ophthalmologique,  par  M.  Guillie.     Tome  i.  p.  74.    Paris,  1820. 


293 

age,  who  used  to  play  with  the  other  boys.  He  caught  the  oph- 
thalmia, and  on  the  fourth  or  fifih  day  after  it  appeared,  his  sister, 
a  child  two  years  old,  was  seized,  and  some  days  alter  this  the  lady 
herself  took  it. 

"  These  circumstances  gave  alarm,  and  particular  attention  was 
paid  to  the  immediate  separation  of  those  who  had  any  symptoms 
of  the  disease,  from  the  other  sick,  and  the  olher  means  usually 
adopted  for  checking  the  progress  of  contagion  were  had  recourse  to. 
^'  In  July,  the  ophthalmia  continued  to  spread,  and  several  of 
those  children  who  had  already  had  it,  and  were  recovered,  took 
it  a  second  time.  Sixty-five  boys  and  thirty  girls  were  attacked 
this  month.  They  appeared  to  have  the  disease  more  severely, 
and  did  not  so  readily  get  well,  as  those  affected  in  the  preceding 
months,  although  treated  in  the  same  manner.  The  weather  was 
much  hotter  than  it  had  been  the  month  before. 

"  In  August,  sixty-nine  boys,  and  twenty-one  girls,  caught  the 
disease ;  a  boy  and  a  girl,  brought  by  their  mother  from  Scotland, 
arrived  at  the  Asylum  one  evening  in  the  end  of  this  month,  and 
were  immediately  admitted.  The  children  w'ere  put  by  the  nurse, 
without  my  knowledge,  into  a  ward  occupied  by  patients  affected 
with  ophthalmia ;  on  visiting  the  Infirmary  next  forenoon,  I  direct- 
ed the  children  to  be  immediately  removed  into  another  ward. 
This  was  accordingly  done ;  yet  on  the  third  morning  after  their 
arrival  both  the  children  had  symptoms  of  ophthalmia,  which  in 
no  respect  differed  from  what  were  observed  in  the  others. 

"  All  the  boys  from  five  to  six  and  a  half  years  of  age  are  formed 
into  one  company.  It  was  observed  that  in  the  course  of  the  last, 
and  present  month,  almost  the  whole  of  this  company  took  the 
ophthalmia.  Its  progress  could  in  their  dormitories  be  traced  from 
one  bed  to  another,  in  the  order  in  which  they  were  placed,  until 
nearly  the  whole  were  affected.  The  two  nurses  attached  to  this 
company  always  slept  in  their  w^ards,  and  were  the  only  nurses 
belonging  to  the  Institution,  (those  connected  with  the  Infirmary 
excepted),  that  suffered  from  the  disease.  About  the  middle  of 
this  month,  I  caught  it  myself;  and  though  the  inflammatory 
symptoms  subsided  in  ten  days,  I  did  not  recover  from  its  effects 
in  five  or  six  weeks. 

"  In  September,  sixteen  boys  and  four  girls  took  the  disease  ;  in 
October,  sixteen  boys  and  seven  girls  ;  in  November,  nine  boys  and 
six  girls ;  and  from  the  twenty-second  of  this  month  to  the  end  of 
December,  only  two  instances  of  it  occurred,  and  these  were  in  two 
boys,  brothers,  who  had  slept  together,  and  had  laboured  under  the 
disease  in  the  month  of  August  in  a  violent  degree. 

"  From  the  above  statement  of  the  progress  of  this  ophthalmia, 
there  is  much  reason  to  suppose  that  it  was  contagious.  For  if  the 
disease  had  been  first  produced,  and  afterwards  kept  up,  by  any 
general  cause,  (as  a  peculiar  state  of  the  atmosphere),  the  girls 
would  have  been  as  subject  to  it  in  the  first  instance,  as  the  boys, 


294 

and  the  officers,  Serjeants,  and  nurses  of  the  institution,  generally, 
would  have  been  as  Hable  to  it,  as  the  persons  of  tlie  same  descrip- 
tion, that  were  immediately  about  the  sick.  But  thiis  was  not  the 
case ;  it  had  prevailed  among  the  boys  for  near  a  month  before  the 
girls  were  attacked,  and,  as  appears  by  the  preceding  statement,  all 
the  adults,  who  did  not  mix  with  the  sick,  escaped  the  disease, 
while  those  who  were  connected  with  them  all  suffered  from  it,  the 
assistant-surgeon  excepted. 

"  The  disease  sometimes  shewed  itself  as  early  as  the  third  day 
after  exposure  to  infection.  This  was  clearly  proved  in  the  cases 
of  the  two  children  from  Scotland. 

'•  It  would  appear  also,  that  closer  connexion  with  the  affected 
person  was  necessary  to  produce  it,  than  what  is  requisite  in  most 
other  contagious  diseases.  This  may  be  inferred,  from  the  ser- 
vants of  the  Infirmary,  and  the  two  nurses  that  attended  the  little 
boys,  taking  it  so  readily,  while  the  other  servants  of  the  institution 
escaped  it. 

"  It  was  influenced  by  the  state  of  the  atmosphere,  being  much 
more  severe  in  its  attacks,  and  of  longer  duration,  in  hot  sultry 
weather,  than  during  cold  or  moderate  weather.  This  was  clearly 
seen  in  July,  August,  and  September,  when  the  disease  was  un- 
usually severe,  and  of  longer  duration,  than  before  or  after  those 
months. 

"  There  is  reason  to  think,  that  it  was  most  contagious  in  its 
early  stage,  w^hen  the  inflammation  was  active,  and  there  was  a 
considerable  purulent  discharge."  * 

Treatment.  1.  Blood-letting.  When  we  have  the  charge  of 
the  patient  from  the  very  beginning  of  the  disease  I  beheve  it  may, 
in  general,  be  cured  by  the  treatment  already  recommended  for  ca- 
tarrhal ophthalmia.  Should  we  be  later  of  being  called  in,  and 
especially  if  chemosis  be  already  present,  bleeding  from  the  arm  to 
the  extent  of  from  10  to  40  ounces,  according  to  the  age  and  con- 
stitution of  the  patient,  followed  by  leeches  round  the  eye,  will  be 
necessary,  and  ma}^  be  repealed  according  to  circumstances.  The 
blood  from  the  arm  should  be  taken  from  a  large  orifice,  while  the 
patient  si'.s  or  stands  up,  so  as  to  ensure  syncope.  The  leeches,  in 
number  from  6  to  24,  should  be  applied  within  two  hours  after  the 
bleeding  from  the  arm.  They  ought  not  to  be  set  on  the  lids,  es- 
pecially if  the  integuments  are  already  swoln  and  red,  as  in  that 
case  the  bites  are  apt  to  fester. 

We  ought  neither  to  delay  the  abstraction  of  blood,  if  the  symp- 
toms are  smart,  and  the  case  of  some  days'  standing  ;  nor  ought 
we,  on  the  other  hand,  to  indulge  in  the  absurd  expectation  that 
profuse  blood-letting  is  to  check  the  disease  completely,  without  the 
use  of  local  apphcations.  1  hold  any  notions  of  this  kind,  which 
some  may  have  entertained,  as   crude  and  irrational,  and  their 

*  Transactions  of  a  Society  for  the  Improvement  of  Medical  and  Chirurgical 
Knowledge,  Vol.  iii.  p.  31.     London,  1812. 


295 

practice  as  perhaps  the  most  destructive  which  could  be  followed. 
By  very  profuse  blood  letting,  the  patient  is  too  much  reduced,  and 
the  eye  rendered  more  susceptible  of  disorganization.  We  must 
not  for  a  moment  indulge  in  the  fancy  that  the  stream  of  blood  is 
to  be  allowed  to  flow,  till  the  redness  of  the  eye  fades  under  our 
view,  nor  are  we  even  to  make  the  cessation  of  pain  in  the  eye  the 
condition  for  stopping  the  bleeding.  These  effects  might  not  be 
obtained  by  abstracting  50  or  60  ounces  of  blood,  whereas  the 
same  real  benefit  will  follow  in  the  course  of  an  hour  or  two,  if  not 
more  than  20  or  30  be  taken,  the  patient  will  be  less  debilitated, 
and  the  course  of  the  disease  will  with  greater  certainty  be  abridged. 

Bleeding  from  the  arm  may  with  propriety  be  repeated,  if  in  the 
course  of  24  or  36  hours  after  the  first  venesection,  the  symptoms 
have  not  abated,  or  have  increased  in  severity.  Afterwards,  also, 
should  there  be  any  signs  of  a  renewal  of  inflammatory  action, 
more  blood  is  to  be  taken  away.  It  is  chiefly  in  cases  where  there 
is  pulsative  pain  in  the  eyeball,  and  circum-orbital  pain,  coming  on 
in  nocturnal  paroxysms,  that  repeated  general  blood-letting  is  ne- 
cessary. 

Besides  venesection,  and  the  application  of  leeches  to  the  temple, 
scarification  of  the  conjunctiva  of  the  eyelids,  and  even  of  the  eye- 
ball, is  to  be  employed.  This  may  be  repeated  every  second  or 
third  day.  In  the  swoln  and  fleshy  state  of  the  conjunctiva  which 
attends  this  disease,  deep  incisions  may  be  made ;  they  will  bleed 
very  copiously,  and  greatly  allay  the  symptoms.  I  am  disposed  to 
place  scarification  of  the  conjunctiva  among  the  most  effectual 
means  of  combating  the  contagious  puro-mucous  ophthalmia. 

2.  Diet.  The  patient  is  to  remain  at  rest,  in  a  well  ventilated 
apartment,  his  eyes  shaded  from  the  light,  and  to  adhere  strictly  to 
the  antiphlogistic  regimen. 

3.  Purgatives.  In  mild  cases,  blood-letting,  at  least  general 
blood-letting,  will  not  be  necessary ;  but  in  all  cases  pui'gatives  are 
to  be  used.  A  dose  of  calomel  and  jalap  may  be  given  at  first,  and 
either  repeated  from  time  to  time  during  the  course  of  the  treatment, 
or  changed  for  some  of  the  neutral  salts.  Purgatives  operate  not 
merely  by  depleting,  but  have  a  strong  sympathetic  effect  upon  the 
conjunctiva.  Emeto-purgatives,  as  tartar  emetic  with  sulphate  of 
magnesia,  will  be  found  highly  useful. 

4.  Diajihoretics.  As  soon  as  the  active  inflammation  is  sub- 
dued, much  advantage  will  be  derived  from  promoting  the  action 
of  the  skin.  For  this  purpose  the  warm  pediluvium  is  to  be  used 
at  bedtime ;  after  wliich  the  patient  may  take  from  10  to  20  grains 
of  Dover's  powder.  The  action  of  these  remedies  may  be  assisted 
by  draughts  of  tepid  diluents,  and  during  the  day  by  small  doses 
of  antimony  or  acetate  of  ammonia. 

5.  Alteratives.  Nexi  to  copious  venesection,  no  remedy  will  be 
found  more  useful  in  severe  cases,  attended  by  nocturnal  circumorbital 
pain,  than  calomel  with  opium.     Two  grains  of  the  former  with 


296 

one  of  the  latter,  may  be  giveu  in  the  form  of  pill  every  evening  at 
bedtime,  till  the  rnouth  is  sore. 

6.  Bark  and  other  tonics  are  to  be  tried  only  in  the  chronic  stage. 
They  are  then  highly  useful. 

Local  treatment.  If  no  local  remedies  are  employed,  or  only 
improper  ones^  the  eyes  may  be  lost,  notwithstanding  the  "best  directed 
general  tieatment.  It  may  to  some  appear  paradoxical,  that  the 
local  applications  in  this  disease  ought  to  be  alternately  soothing 
and  stimulating.  Were  we  to  trust  to  either  sort  alone,  we  should 
endanger  the  eyes.  Soaking  them  constantly  with  tepid  water,  or 
laying  emollient  cataplasms  over  them,  would  be  almost  certain 
destruction :  and,  on  the  other  hand,  a  perpetual  succession  of  stimu- 
lating solutions  and  salves  would  be  not  less  detrimental.  The 
bad  effects  of  a  continued  soothing  or  emollient  local  treatment,  are 
well  illustrated  in  the  history  already  quoted  of  the  Fi-ench  slave- 
ship  at  sea,  while  the  good  effects  of  stimulants  are  shewn  by  the 
rapid  improvement  which  followed  the  negress's  prescription  of 
lemon-juice,  on  the  patients  going  on  shore  at  Guadaloupe.  Ap- 
plications which  smart  the  eye  are  also  employed  by  the  native 
Africans  in  their  own  country  for  the  cure  of  this  ophthalmia.* 
The  Egyptians  employ  urine  for  the  same  purpose.  Sea  water, 
and  a  solution  of  common  salt  have  been  found  useful. 

1.  Cleaning  the  eyes.  The  first  point  in  the  local  treatment 
is  to  clean  away  completely  and  frequently,  in  the  course  of  the 
day  and  night,  the  puriform  discharge.  This  is  to  be  done  with  a 
small  syringe,  the  fluid  employed  being  sent  over  the  whole  surface 
of  the  conjunctiva  with  considerable  force,  but  especially  into  the 
fold  between  the  eyeball  and  the  upper  eyelid.  The  fluid  which  I 
recommend  is  a  tepid  solution  of  one  grain  of  corrosive  sublimate 
in  eight  ounces  of  water.  This  not  only  cleans  the  eye,  but  acts 
also  as  a  gentle  a,stringent. 

2.  Astringents.  With  regard  to  other  astringents,  my  experi- 
ence leads  me  decidedly  to  condenm  sugar  of  lead  and  sulphate  of 
zinc.  They  increase  the  pain,  do  not  abate  the  discharge,  and  are 
apt,  as  1  have  already  stated,  to  injure  the  cornea.  On  the  con- 
trary, the  solution  of  nitras  argenti  allays  the  painful  feeling  of 
sand  in  the  eye,  lessens  the  discharge,  and  never  renders  the  exco- 
riated cornea  opaque.  I  have  tried  this  solution  in  various  degrees 
of  strength;  even  to  10  grains,  as  recommended  by  Dr.  Ridgway,t 
but  4  grains  to  the  ounce  of  distilled  water  appears  to  answer  best, 
applied  once,  or  at  most  twice  in  the  24  hours.  We  generally  find  a 
very  marked  improvement  in  the  course  of  a  few  days,  under  the  use 
of  this  application.  Should  it  disappoint  our  expectations,  and  the 
purulent  discharge  run  on  unabated  for  a  week,  a  solution  of  6 
grains  of  the  sulphate  of  copper  in  an  ounce  of  water  may  be  sub- 

*  See  Yv'inferbottom's  Account  of  the  Natii-e  Africans  in  the  neighbourhood  of 
Sierra  Leone,  Vol.  ii.  p.  129.     London,  1803. 
t  See  the  London  Medical  and  Physical  Journal,  Vol.  liii.  p.  122.     London,  1823 


297 

stituted,  and  used  as  an  injection  over  the  whole  surface  of  the 
cornea. 

3.  To  prevent  the  lids  from  adhermg-.  This  is  effected  by  the 
use  of  the  red  precipitate  ointment,  or  of  the  citrine,  melted  on  the 
end  of  the  finger,  and  rubbed  along  the  edges  of  the  lids  at  bedtime. 
These  applications  fulfil  not  only  the  indication  here  stated,  but 
operate  in  subduing  the  inflammation.  Indeed.  Sir  Patrick  Mac- 
gregor  states  in  his  first  paper,  that  of  all  the  remedies  that  were 
employed  in  the  Military  Asylum,  the  citrine  ointment  was  found 
the  most  frequently  successful. 

4.  Counter-irritants  are  highly  serviceable  in  this  disease,  and 
ought  always  to  be  employed.  There  is  generally  a  marked  change 
in  the  quantity  and  appearance  of  the  discharge  from  the  eye,  as 
soon  as  a  counter-discharge  is  established  by  blisters  on  the  nape  of 
the  neck,  or  behind  the  ears. 

5.  Opiate  fomentations^  and  friction.  Considerable  relief  to 
the  pain  of  the  eye  is  sometimes  obtained  from  allowing  the  steam 
of  hot  water  with  laudanum,  to  rise  into  the  eyes  from  a  teacup  ;  or 
from  fomenting  the  eyes  with  warm  decoction  of  poppy-heads. 
Rubbing  the  head  with  warm  laudanum  when  the  circum-orbital 
pain  threatens  to  commence,  is  also  highly  useful. 

6.  Evacuation  of  the  aqueous  humour  has  been  adopted  as  a 
means  of  relieving  the  severe  pain  of  the  eye  and  head,  and  of 
preventing  bursting  of  the  cornea.  This  is  a  practice  of  which  I 
can  say  nothing  from  my  own  experience  ;  nor  do  I  conceive  it 
will  often  be  required,  if  the  remedies  already  recommended  be  had 
recourse  to.  Sir  Patrick  Macgregor  expresses  his  conviction  that 
many  have  lost  their  sight  from  rupture  of  the  cornea  in  front  of 
the  pupil,  whose  eyes  might  have  been  saved  by  a  timely  and  ju- 
dicious performance  of  this  operation.  Within  two  years  he  had 
performed  it  in  23  instances,  with  a  degree  of  success  which  strongly 
induced  him  to  recommend  it.  The  iris  knife  appears  the  best  in- 
strument for  the  purpose.  The  incision  need  not  exceed  the  tenth 
of  an  inch  in  length,  and  ought  to  be  about  the  same  distance  from 
the  sclerotica. 

7.  Vinwni  opii.  When  the  purulent  discharge  is  gone,  this 
proves  an  excellent  appUcation  to  the  relaxed  conjunctiva. 

Granular  conjunctiva  and  nebulous  coriiea,  two  important  se- 
quelae of  contagious  ophthalmia,  I  shall  consider  in  a  separate  sec- 
tion. Of  the  eversion  of  the  lids,  which  occasionally  proves  a 
troublesome  attendant  on  this  ophthalmia,  I  have  already  treated 
at  page  145. 

Preventives.  To  military  suigeons  especially,  the  means  of 
preventing  this  destructive  disease  are  of  high  importance, 

1.  Supposing  that  troops  were  sent  to  any  of  the  countries  where 

this  disease  prt  ails,  it  would  be  necessary  to  guard  them,  as  much 

as  possible,  against  the  exciting  causes  of  catarrhal  ophthalmia,  in 

which  it  appears  that  the  contagious  originates.     It  is  found  in 

38 


298 

Egypt  that  exposure  to  the  night  air  is  extremely  apt  to  bring  on 
the  ophthalmia  of  the  countr}'.  Soldiers  on  guard,  then,  or  at 
bivouac,  should,  during  the  night,  cover  their  head  well ;  and  if  in 
moist  and  cold  situations,  they  should  avoid  currents  of  air  as  much 
as  possible.  Dr.  Yetch  mentions  that  of  four  officers  who  slept  in 
the  same  tent,  in  Egypt,  tv\'o  had  the  precaution  to  bind  their  eyes 
up  every  night,  when  going  to  rest,  and  the  two  others  did  not ; 
the  latter  were  in  a  very  short  time  attacked  by  the  disease,  while 
the  other  two  escaped. 

2.  As  soon  as  there  are  any  appearances  of  puro-mucous  ophthal- 
mia in  a  regiment,  a  daily  and  minute  inspection  by  the  medical  offi- 
cers, of  every  individual  belonging  to  it,  laecomes  a  duty  of  the  first 
moment,  both  for  the  sake  of  those  who  may  have  caught  the  dis- 
ease, and  for  the  sake  of  their  comrades. 

3.  Those  in  whom  the  disease  is  detected  should  instantly  be 
separated  from  the  rest,  and  must  not  be  allowed  to  join  their  com- 
panies till  perfectly  cured. 

4.  Excessive  crowding  of  the  men  together,  especially  in  their 
dormitories,  must  be  carefully  avoided,  as  this  of  itself  appears  very 
much  to  promote  the  contagious  power  and  the  spread  of  the  dis- 
ease. 

5.  Those  who  are  exposed  to  the  disease  ought  to  be  made  ac- 
quainted with  the  fact  of  its  contagious  nature,  and  warned  against 
the  modes  in  which  it  is  hkely  to  be  communicated  :  as,  touching 
the  e3"es  of  the  diseased  person  and  then  touching  inadvertently 
their  own,  using  the  same  towel  with  those  affected  with  the  ophthal- 
mia, and  the  like.  Barrack-towels  must  afford  a  constant  medium 
for  the  communication  of  this  disease,  and  ought,  therefore,  to  be 
entirely  laid  aside. 

6.  It  will  be  found  a  salutary  practice,  frequently  to  parade  the 
men  in  theh  respective  companies,  wi\h  separate  vessels  of  water, 
while  an  officer  attends  to  see  their  faces  and  eyes  carefuUy 
washed. 


SECTION  VII. OPHTHALMIA  OF  NEW-BORN  CHILDREN. 

Infants,  soon  after  birth,  are  subject  to  a  puro-mucous  inflamma- 
tion of  the  conjunctiva,  commonly  denominated  ophthalmia  neo- 
natorum, or  the  jyurulent  oj^hthalmia  of  infants.  We  have 
reason  to  believe  that  this  disease  is,  in  general,  an  inoculation  of 
the  conjunctiva  hj  leucorrhoeal  fluid,  during  parturition ;  and  that, 
therefore,  it  may  be  prevented,  in  almost  all  cases,  by  carefuUy 
washing  the  eyes  of  the  infant  with  tepid  water,  as  soon  as  it  is 
removed  from  the  mother.  This  is  too  seldom  attended  to :  the 
child  is  allowed  to  open  its  eyes,  the  nurse  sitting  down  with  it  on 
a  low  seat  before  the  fire,  or  in  a  draught  of  cold  air  from  the  door^ 
and  nothing  is  done  to  the  child  for  perhaps  half  an  hour  or  longer. 


299 

Exposure  to^the  light,  to  the  heat  of  the  fire,  or  to  the  cold 
draught  from  the  door,  are  all  likely  enough  injuriously  to  excite 
the  eyes  of  the  new-born  infant ;  and,  accordingly,  some  have  been 
led  to  attribute  the  purulent  ophthalmia  which  so  frequently  shows 
itself  about  the  third  day  after  birth,  to  these  causes.  It  will,  in 
general,  be  found,  however,  that  when  the  child  becomes  affected 
with  this  ophthalmia,  the  mother  has  had  leucorrhoea  before  and 
at  parturition,  and  that  the  eyes  have  not  been  cleaned  for  some 
time  after  birth.  To  this  the  ophthalmia  seems  to  be  owing,  for, 
like  a  disease  communicated  by  contagion,  it  is  sudden  in  its  at- 
tack, and  much  more  violent  than  we  almost  ever  see  catarrhal 
ophthalmia ;  so  that  it  resembles  in  this  respect  the  Egyptian,  or 
the  gonorrhoea!  inflammation  of  the  conjunctiva.  That  some  of 
the  cases  of  purulent  ophthalmia,  in  infants,  are  catarrhal,  is  by  no 
means  unlikely  ;  occasionally  they  may  arise  from  the  application 
even  of  gonorrhoeal  matter  from  the  mother  ;  but  by  far  the  greater 
number,  I  believe  to  be  the  consequences  of  leucorrhceal  inoculation. 

SytniHoms.  It  is  commonly  on  the  morning  of  the  third  day 
after  birth,  that  the  eyelids  of  the  infant  are  observed  to  be  glued 
together  by  concrete  purulent  matter.  On  opening  them,  a  drop 
of  thick  white  fluid  is  discharged,  and  on  examining  the  inside  of 
the  lids,  they  are  found  extremely  vascular  and  considerably  swollen. 
If  neglected,  as  this  disease  but  too  often  is,  or  treated  with  some 
such  useless  application  as  a  httle  of  the  mother's  milk,  the  swell- 
ing of  the  conjunctiva  goes  on  rapidly  to  increase,  the  purulent  dis- 
charge becomes  very  copious,  and  the  skin  of  the  lids  assumes  a 
dark  red  colour.  In  this  state  the  eyes  may  continue  for  eight 
days,  or  a  few  days  longer,  without  any  affection  of  the  transpa- 
rent parts,  except  perhaps  slight  haziness  of  the  cornea.  About 
the  twelfth  day,  however,  the  cornea  is  apt  to  become  infiltrated 
with  pus,  its  texture  is  speedily  destroyed,  it  gives  way  by  ulcera- 
tion, first  of  all  exteriorly  to  the  pus  effused  between  its  lamellae, 
and  then  through  its  whole  thickness,  and  this  either  in  a  small 
spot  only,  or  over  almost  its  whole  extent,  so  that  sometimes  we 
find  only  a  small  penetrating  ulcer,  with  the  iris  pressing  through 
it,  in  other  cases  the  whole  cornea  gone,  and  the  humours  protrud- 
ing. 

It  is  melancholy  to  reflect  on  the  frequency  of  destroyed  vision 
from  this  disease,  especially  as  the  complaint  is  completely  within 
control,  if  properly  treated.  The  attendants  unfortunately  are  not 
alarmed  sutficiently  early,  by  what  they  consider  as  merely  a  httle 
matter  running  from  the  eye  ;  and  but  too  often  it  happens,  that 
medical  practitioners  are  also  betrayed  into  the  false  supposition, 
that  there  is  nothing  dangerous  in  the  complaint,  till  the  cornese 
burst,  and  the  eyes  are  for  ever  destroyed.  Many  children  have 
been  brought  to  me  in  this  state  ;  but  the  most  deplorable  instance 
which  I  have  witnessed  of  the  effects  of  this  disease,  when  neg- 
lected or  mistreated,  was  that  of  two  twin  infants,  from  Perthshire, 


300 

for  whom  I  was  consulted,  some  lime  ago.  One  of  the  children 
had  lost  the  sight  of  both  eyes  totally,  while  the  other  retained  a 
very  partial  vision  with  one  eye. 

That  this  disease  is  a  puro-mucous  or  blencrrhoeal  conjunctivi- 
tis is  sufficiently  evident.  It  is  scarcely  necessary  to  spend  time  in 
refuting  Mr.  Saunders's  notion  of  its  being  an  erysipelatous  inflam- 
mation. His  opinion  regarding  the  mode  in  which  the  cornea  is 
destroyed  in  this  disease  appears  of  more  importanc  and  equally 
incorrect.  He  maintains  that  it  is  by  sloughing,  notb}'  suppuration 
and  ulceration,  that  the  destruction  of  the  cornea  is  effected.  The 
opportunities  which  I  have  had  of  watching  the  progress  of  the 
affection  of  the  cornea  have  convinced  me  of  the  conti'ary.  Onyx 
or  infiltration  of  pus  between  the  lamellae  of  the  cornea  is  the  uni- 
form harbinger  of  destruction  :  the  lamellee  exterior  to  the  pus 
give  way  by  ulceration  ;  the  ulcer  spreads  and  deepens,  till  the  cor- 
nea is  penetrated,  and  often  almost  altogether  destroyed.  Any 
thing  like  mortification,  or  sloughing,  I  have  never  seen.  The 
coming  away  of  the  purulent  infiltration,  exposed  by  ulceration, 
must  have  given  rise  to  Mr.  Saunders'  notion  of  successive  sloughs. 
Infants  labouring  under  this  ophthalmia  are  fretful  and  uneasy, 
and  rest  ill  during  the  night.  The  tongue  is  white,  and  bowels 
deranged.  If  the  disease  is  neglected,  the  flesh  wastes  away,  and 
the  integuments  become  loose  and  iU-coloured. 

Prognosis.     When  a  child  is  brought  to  us  with  this  disease, 
our  first  business  is  carefully  to  clean  and  examine  the  eyes,  ex- 
plaining to  the  nurse  the  manner  in  which  she  is  to  remove  the 
purulent  discharge  from  time  to  time,   and  stating  plainly  what  is 
hkely  to  be  the  result  of  the  morbid  changes  already  present  in  the 
corneae.     If  these  important  parts  are  only  free  from  ulceration, 
and  from  purulent  infiltration,  however  violent  the  inflammation 
may  be  and  profuse  the  discharge,  our  prognosis  may  be  favoura- 
ble— the  sight  is  safe.     If  there  is  superficial  ulceration,  without 
onyx,  probably  a  slight  speck  may  remain.     If  the  ulceration  is 
deep,  an  indelible  opacity  must  be  the  consequence.     If  the  iris  is 
protrading  through  a  small  penetrating  ulcer,  the  pupil  will  be  per- 
manently disfigured,  and  vision  more  or  less  impeded.     If  the  ulcer 
is  directly  over  the  pupil,  the  probabihty  is  that  the  pupillary  edge 
of  the  iris  wiU  adhere  to  the  cicatrice,  and  vision  be  lost  until  a 
lateral  pupil  be  formed  in  after-hfe  by  an  operation.     If  there  is  a 
considerable  onyx,  we  can  promise  nothing,  for  although  under 
proper  treatment,  the  matter  may  be  absorbed,  this  is  by  no  means 
a  certain  result ;  the  purulent  exudation  may,  on  the  contrary,  in- 
crease, the  cornea  burst,   and  the   eye   become  partially  or  totally 
staphylomatous.     Whenever  the  person  who  brings  the  child  to 
me  announces  that  the  disease  has  continued  for  three  weeks,  I 
open  the  lids  of  the  infant  with  the  fearful  presentiment  that  vision 
is  lost,  and  but  too  often  I  find  one  or  both  the  corneae  gone,  and 
the  iris  and  humours  protruding.     In  this  case,  it  is  our  painful 
duty  to  say  that  there  is  no  hope  of  sight. 


801 

Treatment.  1.  As  it  is  of  the  utmost  importance  to  remove  the 
purulent  discharge,  from  time  to  time,  in  the  course  of  the  day,  I 
may  perhaps  be  excused  for  explaining  minutely  how  the  eyes  are 
to  be  cleaned.  The  surgeon  lays  a  towel  over  his  knees,  on  which 
to  receive  the  head  of  the  child,  whom  the  nurse,  sitting  before 
him,  lays  across  her  lap.  The  fluid  for  washing  the  eyes  is  the 
tepid  solution  of  one  grain  of  corrosive  sublimate  in  eight  ounces  of 
water.  The  lids  are  opened  gently,  and,  with  a  small  bit  of  sponge, 
the  purulent  discharge  is  removed.  The  lower  lid,  and  then  the 
upper,  are  next  everted,  and  wiped  clean  with  the  sponge.  The 
upper  lid  has  a  tendency  to  remain  everted,  especially  if  the  child 
cries.  This  is  overcome  by  pushing  the  swoln  conjunctiva  into  its 
place,  and  bringing  down  the  edge  of  the  lid.  All  this  ought  to  be 
repeated  three  or  four  times,  or  oftener,  in  the  twenty-four  hours, 
by  the  nurse. 

2.  The  corrosive  sublimate  coUyrium,  used  in  cleaning  the  eyes, 
tends  gently  to  repress  the  discharge.  Alone,  however,  it  is  not  suf- 
ficient for  that  purpose,  and  we  have  recourse,  therefore,  to  astringent 
apphcations  of  more  power.  The  solutions  of  nitras  argenti  and 
sulphas  cupri  are  those  which  I  have  found  most  useful.  Once,  or 
at  most,  twice  a  day,  I  apply,  with  a  large  camel-hair  pencil,  the 
solution  of  four  grains  of  the  former,  or  six  of  the  latter,  in  an  ounce 
of  distilled  water,  to  the  whole  surface  of  the  inflamed  conjunctiva, 
immediately  after  having  cleaned  it  as  above  described.  Not  only 
the  local,  but  even  the  constitutional  good  effects  of  removing  and 
restraining  the  purulent  discharge  are  very  remarkable.  The  first 
night  after  the  use  of  the  collyrium  and  drops,  we  generally  find 
that  the  infant  has  been  much  quieter  than  it  had  been  when  the 
disease  was  neglected. 

3.  To  prevent  the  eyelids  from  adhering  during  the  night,  the 
red  precipitate  ointment  is  to  be  applied  along  their  edges  at  bed- 
time. 

4.  The  above  remedies  are  perfectly  sufficient  to  remove  this 
disease,  if  had  recourse  to  within  two  or  three  days  after  the  first 
symptoms  have  shown  themselves.  I  have  seen  two  applications 
of  the  nitras  argenti  solution,  viz.  on  the  third  and  fourth  days  after 
birth,  or  first  and  second  days  of  the  disease's  showing  itself,  re- 
move the  complaint  completely,  although  thick  white  matter  had 
been  secreted  by  the  conjxmctiva.  In  cases  attended  by  a  discharge 
less  distinctly  puriform,  the  use  of  the  red  precipitate  salve  at  bed- 
time has  sometimes  been  sufficient.  In  cases,  again,  which  have 
been  neglected  for  perhaps  eight  or  ten  days,  it  is  necessary  to  take 
away  blood  from  the  inflamed  conjunctiva  by  scarification,  or  from 
the  external  surface  of  the  upper  eyelid  by  the  application  of  a  leech. 
The  latter  may  be  had  recourse  to  in  the  first  instance,  and  unless 
followed  by  marked  abatement  of  the  redness  and  swelling  on  the 
inside  of  the  lids,  the  conjunctiva  may  next  day  be  divided  with 
the  lancet.     The  taking  away  of  blood  in  either  of  these  ways  is 


302 

productive  of  much  benefit,  and  ought  by  no  means  to  be  omitted,  if 
there  be  any  tendency  to  cheraosis  or  any  threatening  ^of  haziness 
of  the  cornea.  A  more  profuse  loss  of  blood  than  can  be  ob- 
tained by  the  methods  here  recommended,  I  do  not  consider  neces- 
sary. 

5.  A  remedy  of  great  service  in  this  disease  is  the  application  of 
blisters  behind  the  ears,  or  to  the  back  of  the  head.  Cantharides 
plaster  spread  on  a  bit  of  candle-wick,  and  laid  between  the  head 
and  the  external  ear,  is  a  convenient  mode  of  breaking  the  skin ; 
and  by  continuing  this  apphcation  either  constantly,  or  several 
hours  daily,  a  continued  discharge  will  be  procured.  As  soon  as 
there  is  a  discharge  of  matter  from  the  blistered  parts,  we  find  an 
amendment  in  the  affection  of  the  eyes  ;  but  if  the  ears  are  allowed 
to  get  well,  we  often  observe  a  renewal  of  the  inflammation  of  the 
conjunctiva,  and  a  more  copious  flow  of  puriform  matter,  which 
again  subside  if  the  blisters  are  re-applied. 

6.  An  occasional  dose  of  castor  oil  will  be  found  useful. 

7.  Recovery  from  this  disease  is  often  tedious.  For  weeks,  we 
continue  the  treatment  above  recommended,  and  although  there  is 
no  change  for  the  worse,  nor  any  affection  of  the  cornea,  and  per- 
haps but  little  purulent  discharge,  still  the  conjunctiva  continues 
inflamed,  and  the  symptoms  on  the  whole  stationary.  Under 
these  circumstances,  I  have  found  small  doses  of  calomel  highly 
useful.     From  a  quarter  to  half  a  grain  daily  will  be  sufficient. 

8.  In  threatened  disorganization  of  the  cornea,  Mr.  Saunders 
has  strongly  recommended  the  extract  of  cinchona.  The  sulphate 
of  quina  will  probably  answer  better,  and  be  more  easily  admin- 
istered.    Half  a  grain  may  be  given  twice  or  thrice  daily. 

9.  The  relaxed  conjunctiva,  after  the  purulent  discharge  has 
entirely  subsided,  may  be  advantageously  touched  once  a  day  with 
viimm  opii,  in  place  of  the  metalhc  solutions.  I  have  sometimes 
treated  cases  with  the  vinum  opii  throughout,  but  I  consider  this 
remedy  as  more  applicable  for  the  chronic  stage  of  the  complaint 
than  for  the  acute. 


SECTION    VIII. GONORRHCEAL    OPHTHALMIA. 

Different  views  have  been  entertained  of  the  purulent  inflam- 
mation of  the  conjunctiva,  which  is  frequently  found  to  attend,  or 
succeed  to  gonorrhoea.  1st,  This  ophthalmia  has  been  ascribed 
to  inoculation  with  matter  from  the  urethra ;  2dly,  It  has  been 
supposed  to  be  metastatic ;  and  3dly,  It  has  been  considered  to  be, 
at  least  in  certain  cases,  an  effect  owing  to  irritation  merely,  with- 
out either  inoculation  or  metastasis.  It  is  quite  possible  that  there 
may  be  three  varieties  of  this  ophthalmia,  one  from  contagion,  a 
second  from  suppression,  and  a  third  from  irritation.  The  ex- 
istence of  the  first  I  consider  to  be  beyond  all  doubt ;  that  of  the 
second  and  third  is  somewhat  problematical. 


303 

Some,  while  they  have  admitted  that  facts  have  fully  demon- 
strated that  this  disease  occasionally  owes  its  origin  to  inoculation, 
have  expressed  their  surprise  that  it  is  not  more  frequently  pro- 
duced in  this  way,  considering-  how  common  gonorrhoea  is,  and 
how  careless  many  of  those  of  the  lower  ranks  are  of  cleanliness. 
We  should  expect,  say  they,  the  finger  to  be  in  many  more  cases 
the  conveyer  of  the  matter  of  the  gonorrhoea  to  the  conjunctiva, 
than  it  actually  appears  to  be.  The  instinctive  closure  of  the  eye- 
lids when  the  finger  approaches  the  eye,  making  it  actually  difficult 
for  a  person  to  touch  his  own  conjunctiva,  unless  with  one  finger 
he  draws  down  the  lower  lid,  and  attempts  to  touch  his  eye  with 
another  finger,  will  serve  in  some  measure  to  explain  the  rarity  of 
this  kind  of  inoculation. 

Women  are  much  less  frequently  the  subjects  of  gonorrhoea! 
ophthalmia  than  men. 

In  general,  it  is  only  one  eye  which  is  affected  with  this  disease, 
especially  when  it  arises  from  inoculation. 

1.   Gonorrhmal  Ophthalmia  from  Inoculation. 

Case  1.  A  patient  was  brought  to  me  some  time  ago  from  the 
country  by  a  gentleman  under  whose  care  he  was,  and  who  had 
formerly  been  one  of  my  pupils,  with  his  left  eye  violently  inflamed 
and  chemosed,  the  chemosis  of  a  pale  red  colour,  the  conjunctiva 
discharging  a  large  quantity  of  purulent  fluid,  the  lower  lid  greatly 
everted,  and  the  cornea,  from  lymph,  and  probably  pus  effused  be- 
tween its  lamellae,  totally  opaque.  This  patient  was  affected  with 
gonorrhoea,  and  thirteen  days  before  I  saw  him,  while  engaged  in 
removing  the  discharge  from  the  urethra,  a  drop  of  the  gonorrhoea! 
fluid  was  by  mischance  thrown  fairly  in  upon  his  left  eye,  and 
excited  the  severe  puro-mucous  ophthalmia  under  which  he  was 
labouring.  The  gonorrhoea  still  continued  when  I  saw  liim. 
The  inflammation  of  the  eye  subsided  under  appropriate  means, 
the  cornea  cleared  to  a  degree  far  beyond  my  expectations,  and  a 
considerable  share  of  vision  was  preserved.  The  right  eye  was 
not  at  all  affected. 

Case  2.  Mr.  Allan  relates  the  foUov/ing  interesting  case  of  con- 
tagious gonorrhoeal  ophthalmia.  "  I  was  consulted,"  says  lie,  "  by 
a  young  gentleman  of  17  years  of  age,  on  account  of  a  gonorrhoea 
recently  contracted,  but  by  no  means  severe.  In  a  few  days  after 
his  application  to  me,  the  eyes  became  violently  arid  suddenly  in- 
flamed, the  eyelids  much  tumefied,  and  there  took  place  a  profuse 
discharge,  similar  to  that  of  gonorrhoea,  excoriating  the  cheeks, 
and  accompanied  by  great  pain,  considerable  fever,  and  general 
restlessness;  the  discharge  from  the  urethra  did  not  at  once  disap- 
pear, notwithstanding  the  violence  of  the  ophthalmia.  In  a  few 
days,  his  younger  brother,  a  boy  14  years  of  age,  who  never  had 
been  exposed  to  any  venereal  complaint  contracted  by  sexual  inter- 
course, and  wlio  slept  in  tlie  same  room,  was  similarly  affected ; 


304 

and  the  disease  in  both  eyes  was  equally  severe  as  in  those  of  the 
elder  brother.  I  called  Dr.  Monro  and  Mr.  J.  Bell  into  attendance ; 
but  notwithstanding  every  means  that  could  be  devised,  the  elder 
brother  lost  the  sight  of  both  his  eyes,  and  the  younger  brother  of 
one  eye.  If  it  be  said,"  adds  Mr.  Allan,  "  that  in  the  elder  brother 
the  ophthalmia  might  arise  from  a  consentaneous  connexion  or 
sympathy  betwixt  the  urethra  and  the  conjunctiva,  and  not  from 
the  direct  application  of  the  virus,  still  this  explanation  will  not  at 
all  apply  to  the  younger  brother,  who  had  no  gonorrhoea,  but  who 
must  have  contracted  the  disease  from  actual  contact ;  as  by  using 
the  same  towel  or  wash-hand  basin  with  his  brother,  wiping  his 
face  with  the  same  handkerchief,  or  in  some  less  obvious  manner, 
and  in  whom  it  was  equally  severe."  * 

Case  3.  Astruc  relates,  that  a  young  man  had  been  in  the  habit 
of  every  morning  bathing  his  eyes  with  his  urine  while  it  was  yet 
warm,  in  order  to  strengthen  his  sight.  Although  he  had  con- 
tracted a  gonorrhoea,  he  did  not  abstain  from  this  custom,  appre- 
hending no  harm  from  it ;  but  the  urine  partaking  of  the  infectious 
matter,  quickly  communicated  the  same  disease  to  the  tunica  con- 
junctiva of  the  eye  and  eyelids.  The  consequence  was  a  severe 
ophthalmia,  attended  with  an  acrid  and  involuntary  discharge  of 
tears  and  purulent  matter,  but  which  yielded  to  the  same  remedies 
which  removed  the  gonorrhoea.t 

Case  4.  A  healthy  young  woman  happened  to  wash  her  eyes 
with  some  sugar  of  lead  water  and  a  sponge  which  had  previously 
been  used  by  a  young  man  affected  with  gonorrhoea  ;  the  conse- 
quence was,  that  she  immediately  contracted  a  severe  ophthalmia, 
which  rapidly  destroyed  one  eye,  and  brought  on  swelling  of  the 
lymphatic  glands  about  the  neck,  for  which  she  underwent  a  course 
of  mercury.  J 

So  similar  is  the  discharge  from  the  eye  in  gonorrhoeal  and  in 
Egyptian  ophthalmia,  to  that  which  runs  from  the  lu-ethra  in  gon- 
Qrrhoea,  that  some  have  gone  the  length  of  concluding  that  gonor- 
rhoea has  been  originally  an  inoculation  of  the  urethra  by  the  mat- 
ter coming  from  the  eye  in  Egyptian  ophthalmia  ;  while  others 
are  of  opinion  that  this  last  disease  is  nothing  else  than  the  etfects 
of  an  inoculation  of  the  conjunctiva  with  matter  from  the  urethra 
in  gonorrhoea.  Both  parties  have  referred  to  experiments  in  favour 
of  their  own  opinion.  Little  can  be  drawn  from  negative  experi- 
ments on  this  subject.  It  is  demonstrated  beyond  all  doubt  that 
the  matter  from  the  urethra  in  gonorrhoea,  applied  to  the  conjunc- 
tiva, excites  a  severe  puro-mucous  ophthalmia,  and  a  similar  in- 
flammation of  the  urethra  has  unquestionably  been  brought  on  by 
inoculation  with  the  matter  coming  ffom  the  conjunctiva  in  the 

*  System  of  Pathological  and  Operative  Surgery,  Vol.  i.  p.  153.     Edin.  1819. 
t  De  Mortis  Venereis,  p.  192.     Lutetiae  Parisiorura,  1736. 

t  Chirurgie  Clinique  de  Montpellier,  par  le  Professeur  Delpech.  Tome  i.  p.  318, 
Montpellier,  1823. 


305 

Egyptian  ophthalmia  ;  but  experiments  of  this  kind  have  also 
sometimes  failed,  and  from  such  failures  conclusions  have  been 
drawn  that  are  altogether  unwarrantable.  For  example,  Dr.  Vetch 
tells  us  that  in  the  case  of  a  soldier,  received  in  a  very  advanced 
stage  of  the  Egyptian  ophthalmia,  he  attempted  to  divert  the  dis- 
ease from  the  eyes  to  the  urethra,  by  applying  some  of  the  matter 
taken  from  the  eyes  to  the  orifice  of  the  urethra.  No  effect  followed 
this  trial.  It  was  repeated  in  some  other  patients,  all  labouring 
under  the  most  virulent  state  of  the  Egyptian  disease  ;  and  in  all, 
the  application  was  perfectly  innocuous.  But,  in  another  case, 
where  the  matter  was  taken  from  the  eye  of  one  man,  labouring, 
under  purulent  ophthalmia,  and  applied  to  the  urethra  of  another, 
the  purulent  inflammation  commenced  in  thirty -six  hours  after- 
wards, and  became  a  very  severe  attack  of  gonorrhoea.  From  the 
result  of  these  experiments.  Dr.  Vetch,  while  he  admits  that  gonor- 
rhoea! matter  taken  from  one  person  and  applied  to  the  conjunctiva 
of  another,  will  excite  a  highly  purulent  ophthalmia,  regards  him- 
self justified  in  no  longer  admitting  the  possibility  of  infection  being 
conveyed  to  the  eyes  from  the  gonorrhoeal  discharge  of  the  same 
person.  He  adds  that  the  impossibihty  of  this  eflfect,  was  rendered 
decisive  by  an  hospital-assistant,  who,  with  more  faith  than  pru- 
dence, conveyed  the  matter  of  a  gonorrhoea  to  his  eyes  without  any 
affection  of  the  conjunctiva  being  the  consequence.*  It  is  remark- 
able, that  Dr.  Guillie  has  fallen  into  the  same  error  of  reasoning 
with  Dr.  Vetch,  only  that  his  negative  experiments  have  led  him 
to  the  very  opposite  conclusion.  He  applied  the  matter  taken  from 
the  conjunctiva  of  one  patient  to  the  urethra  of  another  ;  no  effect 
followed,  and  hence  he  concludes  that  the  notion  of  some,  regarding 
the  propagation  of  puro-mucous  inflammation  from  one  mucous 
membrane  to  another  in  different  individuals,  is  unfounded.t 

The  first  case  which  I  have  related  would  have  been  sufficiently 
convincing  to  me  of  the  reality  of  gonorrhoeal  ophthalmia  by  inoc- 
ulation, had  I  entertained  any  doubt  upon  the  subject.  The  man 
had  a  profuse  gonorrhoea,  but  his  eyes  were  perfectly  well ;  shaking 
away  the  discharge  from  the  penis,  and  stooping  at  the  time,  a 
drop  went  fairly  in  on  the  left  eye,  violent  inflammation  imme- 
diately set  in,  was  all  along  confined  to  the  eye  which  had  been 
inoculated,  and  produced  the  results  already  stated,  while  the  gon- 
orrhoea continued  to  run  its  course. 

Diagnosis.  There  are  no  marks  which  can  be  absolutely  de- 
pended on,  by  which  to  distinguish  gonorrhoeal  ophthalmia,  pro- 
duced by  inoculation,  from  the  Egyptian  or  contagious  ophthalmia. 
The  symptoms  of  the  former  are  not  less  rapid  and  severe  than 
those  of  the  latter ;  and  the  danger  of  losing  the  eye,  by  destruc- 
tion of  the  cornea,  greater  perhaps  than  in  any  other  ophthalmia. 
There  is  a  great  degree  of  chemosis,  and  a  profuse  discharge  of 

*  Practical  Treatise  on  the  Diseases  of  the  Eye,  p.  242.    London,  1820. 
+  Biblioth^quc  Ophthalmologique.    Tome  i.  pi  83.    Paris,  1820. 

39 


306 

matter,  varying  in  colour  like  the  discharge  in  gonorrhoea.  The 
external  surface  of  tiie  hds  is  perhaps  not  so  rnucli  swoln,  nor  of 
so  dark  a  red  colour,  as  in  the  Egyptian  ophthalmia.  In  the  early 
stage,  it  will  also  be  observed,  that  in  the  latter  disease,  the  inflam- 
mation commences  on  the  inside  of  the  hds  :  whereas  in  gonor- 
rhoeal  ophthalmia,  it  attacks  the  whole  conjunctiva  at  once.  The 
history  of  the  two  diseases  will  perhaps  afford  the  best  ground  for 
diagnosis. 

Treatment.  This  ought  to  be  exactly  the  same  as  in  the  Egyp- 
tian ophthalmia.  Abstinence  from  all  stimulants ;  blood-letting, 
both  general  and  local :  and  the  exhibition  of  purgatives,  or  emeto- 
purgativeS;  and  diaphoretics,  are  to  be  had  recourse  to  in  the  early 
stage.  The  discbarge  is  to  be  frequently  and  carefully  removed 
with  the  muriate  of  mercury  coUyrium,  the  conjunctiva  is  to  be 
touched  once  or  tvace  a  day  with  the  nitras  argenti  solution,  and 
the  lids  are  to  be  prevented  from  adhering  by  the  use  of  the  red 
precipitate  salve.  Oounter-kiitation  ought  to  be  employed  from 
the  very  first,  by  means  of  sina,pisms  and  blisters  to  the  neck,  be- 
tween the  shoulders,  or  tehind  the  ears.  If  either  the  pain  of  the 
eye  is  pulsative,  or  the  circum-orbital  region  affected  with  noctur- 
nal paroxysms  of  pain,  calomel  and  opium  are  to  be  given,  till  the 
mouth  is  sore.  Warm  fomentations,  the  vapour  of  laudanum, 
opiate  Mction  of  the  head,  and  the  like,  will  serve  to  moderate  the 
pain  ;  but  our  chief  rehance  must  be  placed  on  depletion,  counter- 
irritation,  scarification,  and  smarting  applications  to  the  conjunctiva, 
for  removing  the  disease.  Snipping  out  a  portion  of  the  chemosed 
membrane,  so  as  to  procure  a  considerable  flow  of  blood,  is  highly 
serviceable. 

Bleeding  alone  must  not  be  depended  on.  "  The  inflammation 
produced,"  says  Mr.  Bacot,  "  in  the  four  instances  that  have  come 
under  my  observation,  is  of  the  most  violent  and  intractable  des- 
cription, and  has  produced  the  total  destruction  of  the  organ  of 
vision,  in  the  space  of  two  or  three  days,  notwithstanding  the  most 
vigorous  employment  of  general  and  topical  blood-letting,  and 
other  antiphlogistic  means."  * 

The  acetate  of  lead  and  the  sulphates  of  zinc  and  copper,  at  least 
in  the  early  stage,  will  be  found  to  aggravate  the  symptoms.  These 
are  the  local  remedies  recommended  by  Mr.  Allan  ;  and  the  case 
already  quoted,  the  pubhcation  of  which  does  great  credit  to  his 
candour,  shows  how  httle  adapted  these  applications  are  to  this  dis- 
ease. 

2.   Gonorrhceal  Ophthalmia  from  Metastasis. 

The  doctrine  of  related  diseases,  or  of  the  conversion  of  one 
disease  into  another,  is  at  once  one  of  the  most  important  and  difli- 
cult,  in  the  whole  science  of  medicine. 

*  Observations  on  Syphilis,  p.  46.    London,  1821. 


307 

Perhaps  the  most  famihar  example  of  a  metastasis,  or  conversion 
of  disease,  is  swelled  testicle  following  suppressed  gonorrhoea  ;  but 
no  one  supposes  that  in  this  case,  there  is  actually  a  translation  of 
matter  from  the  urethra  into  the  testicle. 

The  most  dangerous,  as  well  as  the  best-proven,  translation  is 
that  which  attends  the  inflammation  of  veins.  For  instance,  caus- 
'  tic  potass  was  directed  to  be  applied  on  the  outer  side  of  the  leg, 
below  the  knee,  for  the  purpose  of  forming  an  issue.  By  mischance, 
it  was  applied  over  one  of  the  branches  of  the  external  saphena. 
The  eschar  fell  out  and  was  found  to  have  penetrated  into  the  vein, 
which  immediately  bled  profusely.  A  bit  of  sponge  was  applied, 
and  kept  in  its  place  by  a  roller.  The  vein  inflamed,  violent  fever 
ensued,  and  the  patient  died.  Before  his  death,  a  considerable 
swelling,  communicating  to  the  hand  a  peculiar  kind  of  crepitation, 
had  formed  under  one  of  the  pectorales  majores.  On  dissection, 
this  swelling  was  found  to  consist  of  a  large  collection  of  pus. 
Within  the  veins,  purulent  matter  was  traced  from  the  external 
saphena  to  the  commencement  of  the  inferior  vena  cava.  The  ex- 
planation which  has  generally  been  adopted  of  metastatic  cases 
like  this,  is  that  the  pus,  mingling  with  the  blood,  is  circulated 
through  the  body,  and  by  its  presence,  excites  inflammation  in 
parts  remote  from  the  seat  of  the  original  injury. 

In  various  parts  of  the  body,  and  among  others  in  the  eye,  in- 
flammation, ending  in  suppuration  and  sometimes  in  ulceration,  has 
been  known  to  arise  from  inflamed  veins.  A  highly  interesting 
case  of  this  kind  occurred  to  Mr.  Earle.  He  had  removed  a  por- 
tion of  a  varicose  vein  of  the  leg.  This  was  followed  by  great  con- 
stitutional disturbance,  inflammation  of  the  vein,  deep-seated  ab- 
scesses in  the  opposite  leg,  in  both  forearms,  and  in  one  of  the  lungs. 
The  day  before  the  patient's  death,  the  corneee  were  observed  to 
have  become  opaque,  and  their  surface  rough,  the  vessels  of  the 
conjunctiva  were  injected,  and  the  patient  lay  with  his  eyes  con- 
stantly closed.  On  dissection,  destructive  changes  were  found  to 
have  taken  place  within  the  globe  of  the  right  eye,  the  chrystalline 
lens  was  so  soft  as  to  v\e\d  to  the  shghtest  touch,  the  vitreous  hu- 
mour was  of  a  reddish  yellow  colour,  and  red  vessels  were  distinctly 
seen  traversing  its  membrane.  The  retina  was  of  a  deep  red  col- 
our. The  nerve  of  the  third  pair  on  the  left  side  was  evidently  flat- 
tened, and  softer  than  that  on  the  right.  The  nerve  of  the  fifth  pair 
on  the  right  side  iiad  undergone  a  similar  change  to  a  greater  ex- 
tent.* This,  then,  appears  to  have  been  a  destructive  inflammation 
of  the  eye,  arising  from  the  transmission  of  pus  into  the  circulation, 

A  similar  case  is  recorded  by  Mr.  Arnott,  in  his  valuable  paper 
on  the  Secondary  Effects  of  Inflammation  of  the  Veins,  published 
in  the  fifteenth  volume  of  the  Medico-Chirurgical  Transac'ions. 
A  young  man  had  a  hgature  placed  on  the  left  .carotid  artery,  for 

*  London  Medical  Gazette,  Vol.  ii.  p.  284.    London,  1828, 


308 

an  aneurismal  disease  of  one  of  its  branches.  Considerable  diffi- 
culty was  experienced  in  passing  the  needle  round  the  vessel.  Ven- 
ous hsemorrhage  took  place  during  the  operation,  recurred  at  night, 
and  occasionally  afterwards,  for  nine  or  ten  days.  On  the  fifth  day 
after  the  operation,  the  patient  had  a  severe  rigor,  succeeded  by  heat 
of  skin,  and  general  febrile  symptoms.  These  increased,  the 
pulse  rose  to  120,  and  the  constitutional  disturbance  assumed  a  very 
violent  character.  About  the  tenth  day,  the  vision  of  the  left  eye 
became  impaired,  and  was  quickly  lost,  the  pupil  was  contracted, 
the  iris  immovable,  and  the  cornea  had  a  somewhat  hazy  appear- 
ance ;  effusion  took  place  under  the  conjunctiva,  and  the  lids  were 
greatly  swoln,  producing  an  appearance  as  if  the  globes  were  much 
protruded.  There  was,  at  the  same  time,  a  degree  of  deafness, 
considerable  stupor,  and  occasionally  slight  delirium.  In  the  course 
of  a  few  days,  the  coats  of  the  eye  sloughed  at  the  upper  part,  and 
its  contents  w^ere  evacuated.  While  these  changes  were  going  on 
in  the  eye,  collections  of  matter  formed,  without  pain,  in  different 
parts  of  the  body,  on  both  shoulders,  above  the  insertion  of  the  del- 
toid muscles,  over  the  sacrum,  &c.  The  constitutional  disturbance 
abated,  and  the  collapsed  eye  healed  over ;  but  the  patient  never 
recovered  his  health.  He  died  five  months  after,  labouring  under 
lumbar  abscess,  and  worn  out  by  hectic.  On  examination  of  the 
body,  a  portion  of  the  jugular  vein,  to  the  extent  of  two  inches,  was 
found  wanting  ;  the  upper  and  lower  ends  next  the  lost  part  being 
shrunk,  hgamentous,  and  gradually  lost  in  the  cellular  substance. 
On  opening  the  head,  pus  was  found  effused  in  great  quantity  be- 
tween the  tunica  arachnoidea  and  pia  mater,  along  the  base  of  the 
brain,  and  the  w^hole  length  of  the  spinal  cord.  The  intermuscu- 
lar cellular  substance  of  the  loins  was  loaded  with  pus.  Mr.  Arnott 
asks,  when  we  consider  the  circumstances  of  this  case,  the  venous 
haemorrhage,  constitutional  disturbance,  formation  of  abscesses,  and 
appearances  presented  on  dissection,  and  compare  them  with  the 
consequences  which  have  been  observed  to  follow  inflammation  and 
suppuration  of  a  vein,  and  the  occurrences  in  Mr.  Earle's  case,  whe- 
ther we  can  doubt  that  the  affection  of  the  eye.  in  this  instance, 
arose  from  the  inflammation  of  the  jugular  vein,  and  from  the  en- 
trance of  an  inflammatory  secretion,  probably  pus,  into  the  blood. 

I  have  quoted  these  facts,  both  as  interesting  in  themselves,  and 
as  illustrative  of  the  doctrine  of  metastasis.  It  is  evident  that  if  a 
destructive  inflammation  of  the  eye  can  be  excited  in  consequence 
of  the  suppuration  of  a  remote  vein,  a  metastatic  ophthalmia  from 
suppurative  inflammation  of  the  urethra  must  be  regarded  as  not  so 
improbable  an  event  as  some  have  been  disposed  to  consider  it. 

There  is  a  set  of  cases,  however,  in  themselves  highly  important, 
and  still  more  confirmatory  of  the  possibility  of  a  metastatic  gonor- 
rhoea! ophthalmia.  A  disease  of  the  eye,  similar  to  that  observed  in 
the  two  cases  above  mentioned,  occurring  in  the  puerperal  state,  has 
been  described  by  Dr.  Hall  and  Mr.  Higginbottom,  in  a  paper  pub- 


309 

lished  in  the  thirteenth  volume  of  the  Medico-Chirurgical  Transac- 
tions, under  the  title  of  "  Cases  of  Destructive  Inflammation  of  the 
Eye,  and  of  Suppurative  Inflammation  of  the  Integuments,  occur- 
ring in  the  Puerperal  State,  and  apparently  from  Constitutional 
Causes."  In  all  of  these  cases,  six  in  number,  the  affection  of  the 
eye  took  place  in  from  five  to  eleven  days  after  delivery.  It  was 
preceded  and  accompanied  by  serious  indisposition,  in  every  instance 
terminating  fatally,  and  under  symptoms  of  extreme  exhaustion. 
The  affection  of  the  eye  was  characterized  by  redness  of  the  con- 
junctiva, intolerance  of  hght,  and  contracted  pupil,  rapidly  followed 
by  opacity  of  the  cornea,  and  excessive  chemosis.  In  two  of  the 
cases,  the  coats  of  the  eye  gave  way ;  and  in  one  of  these,  where 
the  process  was  observed,  the  rupture  took  place  by  ulceration  of 
the  coats  round  the  cornea.  In  both  of  these  cases,  the  collapsed 
globe  had  healed  over  previous  to  death.  In  each  instance  only 
one  eye  was  affected,  and  in  five  of  them  it  was  the  left. 

In  the  case  communicated  by  Mr.  Ward,  it  does  not  appear  which 
eye  was  the  seat  of  the  disease.  With  the  disease  of  the  eye,  there 
also  took  place  an  inflammation  of  the  integuments,  first  observed 
on  the  hand,  but  on  careful  examination,  found  in  the  inferior,  as 
well  as  the  superior  extremities,  and  under  which,  matter  quickly 
formed.  In  one  case  only,  there  was  no  such  inflammation.  The 
authors  of  the  paper  conjecture,  that  the  morbid  affection  of  the  eye 
had  a  constitutional  origin.  No  examination  after  death  seems  to 
have  been  made  in  any  of  the  cases.  Mr.  Arnott,  in  his  comments 
on  these  cases,  asks,  whether,  considering  the  circumstances  under 
which  the  affection  of  the  eye  took  place,  its  character,  and  the 
depositions  of  pus  under  the  integuments  of  the  body,  and  com- 
paring these  with  the  known  consequences  of  inflammation  of  veins, 
and  the  frequency  of  inflammation  in  the  veins  of  the  uterus  after 
parturition,  we  may  not  be  justified  in  attributing  the  disease  of  the 
eye  to  inflammation  of  the  uterine  veins,  and  the  introduction  of  pus 
into  the  circulation.  He  cautions  us  against  supposing  him  to 
regard  the  matter  deposited  in  different  parts  of  the  body,  under 
such  circumstances,  to  be  actually  that  which  has  been  brought  into 
the  circulation  from  the  inflamed  vein  or  veins ;  stating  that  the 
question  is  no  longer  one  of  a  translation  of  matter  merely,  but  one 
which  involves  the  very  difficult  subject  of  the  pathology  of  the 
blood.  Indeed,  in  these  cases,  although  inflammation,  ending  in 
suppuration,  occurred  in  the  extremities,  no  deposition  of  pus  appears 
to  have  taken  place  in  the  inflamed  eye. 

I  owe  to  Mr.  James  Brown  of  this  city,  the  opportunity  of  seeing 
a  case  of  puerperal  ophthalmia,  which  I  have  now  no  doubt  was 
of  the  nature  of  the  cases  recorded  by  Dr.  Hall  and  Mr.  Higgin- 
bottom.  The  patient  was  a  slender  scrofulous  woman,  about  30 
years  of  age,  of  irritable  temperament,  sedentary  habits,  and  mel- 
ancholy disposition.  She  had  been  seven  times  pregnant,  and  the 
following  numbers  indicate  the  months  during  which  each  utero- 


310 

gestation  was  continued  ;  viz.  9,  7,  5,  9,  9,  7,  4.  She  had  formerly- 
been  subject  to  discharge  from  the  vagina,  probably  leucorrhceal, 
but  not  immediately  before  the  abortion  in  the  fourth  month,  which 
led  to  her  last  illness.  There  was  nothing  remarkable  about  the 
labour.  The  lochial  discharge  was  scanty,  and  did  not  continue 
above  a  week,  at  the  end  of  which  time  she  began  to  complain  of 
pain  in  the  back  and  groins,  accompanied  with  slight  colds  and  heats, 
and  little,  if  at  all,  relieved  by  blood-letting  and  purging,  both  of  which 
were  copiously  used.  Some  fifteen  or  eighteen  days  after  delivery, 
she  was  seized  with  very  severe  rigors,  followed  by  great  pain  in 
the  head,  back,  and  abdomen ;  the  pain  in  the  abdomen  being 
complained  of  chiefly  on  pressure.  The  affection  of  the  eye,  which, 
as  in  the  cases  already  referred  to,  was  the  left,  came  on  about 
twenty-eight  or  thirty  days  after  the  former  symptoms  had  been 
apparently  subdued  by  the  usual  means,  although  during  all  this 
time,  the  general  state  of  the  patient  had  been  by  no  means  favour- 
able. The  affection  of  the  eye  was  ushered  in  by  new  rigors,  which 
were  followed  by  a  good  deal  of  fever,  rather  of  a  remittent  type, 
and  occasional  feelings  of  sinking.  The  pulse  continued  from  the 
first  quick,  irritated,  and  by  no  means  strong.  The  eye  was  highly 
inflamed,  the  conjunctiva  much  chemosed,  the  hds  swoln,  and  the 
lower  lid  everted.  There  was  severe  pain  in  the  eye  and  head, 
and  excessive  intolerance  of  light,  so  much  so  that  she  was  obhged 
to  keep  her  face  covered  with  a  handkerchief,  although  the  window- 
shutters  were  kept  constantly  closed.  At  first  tears  ran  from  the 
eye,  and,  after  a  time,  purulent  matter.  The  cornea  became 
opaque,  but  the  eye  did  not  burst.  Her  mind  was  all  along  very 
desponding.  For  some  days  she  was  shghtly  incoherent,  on  coming 
out  of  sleep,  but  when  roused  was  sensible  to  the  last.  No  abscess 
formed  near  the  surface  of  any  part  of  the  body.  She  died  about 
eight  weeks  after  the  abortion.  It  is  to  be  regretted  that  neither 
the  eye  nor  the  body  was  permitted  to  be  examined. 

It  is  far  from  being  my  intention  to  draw,  from  these  facts,  any 
other  conclusion,  regarding  gonorrhoeal  ophthalmia  by  metastasis, 
than  this,  that  they  render  such  an  affection  somewhat  less  prob- 
lematical. The  facts  themselves  are  valuable,  nor  could  1  omit 
giving  an  account  of  them  under  some  head  or  other. 

Saint- Yves  appears  to  have  been  the  first  to  speak  of  gonorrhoeal 
ophthalmia  from  metastasis.  His  account  of  it  is  very  short.  He 
describes  the  conjunctiva  as  becoming  hard  and  fleshy,  the  disease 
having  commenced  by  an  abundant  discharge  of  white  or  yellowish 
matter.  He  states  that,  in  most  cases,  the  ophthalmia  began  two 
days  after  the  commencement  of  the  gonorrhoea,  the  latter  discharge 
having  at  that  period  suddenly  ceased,  and  thus  caused  a  metas- 
tasis to  the  eye.  He  recommends  blood-letting  from  the  first,  mer- 
cury, purgatives,  and  the  warm  bath.  As  local  applications,  he 
advises  brandy  and  water,  and  a  decoction  of  rosemary,  sage,  hys- 
sop, and  roses  in  red  wine.* 

*  Nouveau  Traite  des  Maladies  dea  Yeux,  pp.  187,  209.     Paris,  1722. 


311 

Succeeding  writers  have  adopted  Saint- Yves's  view  of  the  sub- 
ject with  too  Uttle  hesitation,  and  appear  to  have  investigated  suf- 
ficiently neither  the  probability  of  the  ophthalmia  having  arisen 
rather  from  inoculation  than  from  metastasis,  nor  the  chance  of 
there  being  no  connexion  between  the  two  diseases,  but  merely 
a  concurrence  in  the  same  individual. 

The  causes  of  the  suppression  of  the  gonorrhoea,  to  which  the 
rise  of  metastatic  gonorrhceal  ophthalmia  is  attributed,  are  exposure 
to  cold,  violent  exertions  of  the  body,  the  abuse  of  spirituous  liquors, 
and  the  employment  of  astringent  injections  into  the  urethra. 

The  following  may  serve  as  a  specimen  of  alleged  metastatic 
gonorrhcEal  ophthalmia. 

A  captain  in  the  army,  aged  29,  was  ordered  to  mount  guard  at 
court,  in  the  month  of  January,  when  he  had  a  violent  gonorrhoea. 
The  day  was  excessively  cold,  and  he  was  forced  by  his  duty  to 
remain  a  long  time  exposed  to  the  air  during  the  day  and  night. 
Towards  midnight  he  began  to  feel  the  most  violent  pain  in  both 
eyes  at  once,  which  very  soon  increased  to  such  a  degree  that  he 
could  not  endure  any  kind  of  light.  Next  day,  these  s3rmptoms 
were  attended  by  a  discharge  of  puriform  matter  from  both  eyes, 
and  the  albuginea  appeared  very  much  inflamed  and  swelled.  A 
physician  w^as  sent  for,  unfortunately  very  ignorant,  who  ordered 
general  remedies,  as  bleeding,  purgatives,  <fcc.  with  a  fomentation 
of  hemlock.  The  third  day,  on  examining  things  more  closely, 
the  cornea  was  found  completely  opaque,  and  a  hypopion  formed  ; 
there  appeared  no  ulceration.  The  hemlock  was  continued,  with- 
out any  effect.  Ten  or  twelve  days  after,  the  inflammation  began 
to  abate,  and  the  discharge  from  the  eyes  stopped  ;  but  the  cornea 
did  not  recover  its  transparency,  on  the  contrary,  it  was  extremely 
thickened,  and  the  patient  remained  entirely  Wind  for  life.* 

Treatment.  The  only  point  of  treatment  in  cases  of  metastatic 
gonorrhceal  ophthalmia,  different  from  that  which  is  to  be  followed 
when  the  disease  is  brought  on  by  inoculation,  is  the  attempt,  so 
much  recommended  by  some  authors,  to  restore  the  suppressed  dis- 
charge from  the  urethra.  This  is  to  be  done  by  introducing  a 
bougie  into  the  urethra,  covered  with  some  of  the  purulent  discharge 
from  the  eye,  or  with  gonorrhceal  matter  from  another  subject. 
Even  the  simple  introduction  of  a  bougie  may  perhaps  produce  the 
effect  which  is  desired  ;  for  any  stimulus  applied  to  the  lining  mem- 
brane of  the  urethra,  provided  it  be  of  sufficient  activity  to  determino 
an  irritation  and  an  abundant  secretion  of  mucus,  may  produce  a 
running  similar  to  gonorrhoea.  If  this  plan  is  adopted,  the  bougie 
must  be  retained  in  the  urethra  for  several  hours  at  a  time,  till  the 
desired  effect  is  produced. 

*  Swediaur's  Treatise  upon  the  Symptoms,  Consequences,  Nature,  and  Treatment 
of  Venereal  or  Syphilitic  Diseases.  Translated  from  the  French.  Vol.  i.  p.  245. 
London,  1819. 


312 


3,   Gonorrhceal  Ophthalmia  withoiit  Inoculation  or  Metastasis. 

Various  authors  have  related  cases  of  ophthahnia  occurring  in 
individuals,  who,  either  at  the  time  when  tlie  ophthalmia  attacked 
them,  or  a  short  time  before  its  attack,  had  been  affected  with 
gonorrhoea.  An  alternation  also  has  been  observed  by  these  au- 
thors between  the  two  diseases ;  that  is  to  say,  when  the  gonorrhoea 
came,  the  ophthalmia  went,  and  vice  versa.  The  conclusion 
drawn  from  such  cases  has  been,  that  a  relation  exists  between  the 
two  diseases,  and  that  they  are  convertible  the  one  into  the  other, 
without  being  metastatic.  None  of  the  authors  who  have  described 
the  cases  to  which  I  now  refer,  have  explicitly  attributed  the  pro- 
duction of  the  ophthalmia  in  question  to  the  influence  of  nervous 
sympathy ;  and  yet,  if  we  throw  inoculation  and  metastasis  aside, 
there  appears  to  be  no  other  means  h»y  which  the  diseases  of  remote 
organs  can  be  connected,  except  by  nervous  communication.  The 
facts  recorded  upon  the  subject  are  valuable,  whatever  opinion  we 
ma}^  form  of  the  reasonings  of  those  by  whom  they  are  narrated. 

Case  1.  Swediaur  states  that  a  young  man  in  London  came  to 
consult  him  for  an  ophthalmia.  After  he  had  tried  the  best  reme-: 
dies,  internal  and  external,  that  he  knew  of  for  an  ophthalmia, 
without  effect,  the  patient  left  him.  He  heard  nothing  more  of 
him  for  two  months,  when  he  returned  to  him  with  gonorrhoea. 
During  his  absence  he  had  consulted  several  practitioners  on  account 
of  his  ophthalmia,  but  with  no  better  success  than  before  ;  but 
having  caught  a  gonorrhoea  eight  days  before  returning  to  Swe- 
diaur, he  had  begun  to  feel  his  eyes  better  from  the  third  day  of 
the  discharge.  The  ophthalmia  had  continued  to  diminish  from 
day  to  day,  and  he  was  now  quite  cured  of  it.  Swediaur  asked 
him  if  he  ever  had  had  gonorrhoea  previously  to  the  attack  of  oph- 
thalmia. He  said  he  had  had  it  some  time  before  he  came  to 
consult  him  first  about  his  eyes ;  that  he  had  suffered  much, 
and  for  a  long  time,  with  it,  but  that  at  last  the  discharge  had 
disappeared  ;  and  that  he  had  not  mentioned  it,  as  he  had  not 
supposed  there  was  any  connexion  between  that  gonorrhoea 
and  the  complaint  in  his  eyes,  which  had  come  on  several  weeks 
after. 

Swediaur  tells  us,  that  this  fact  was  too  striking  a  lesson  for  him 
ever  to  forget  it ;  and  that  he  had  never  afterwards  failed,  in  simi- 
lar cases  of  ophthalmia,  to  ask  tlie  patient  if  he  had  not  previously 
had  a  gonorrhoea,  and  if  it  had  been  properly  treated  and  cured. 
He  described  the  ophthalmia  in  cases  of  this  sort,  as  a  chronic  in- 
flammation of  the  eyes,  and  especially  of  liie  eyelids,  attended  very 
often  with  little  ulcers  of  the  sebaceous  glands,  and  with  an  oozing 
of  thick  yellowish  matter.  In  all  such  cases,  especially  when  the 
patients  told  him  that  they  had  tried  many  internal  and,  external 
remedies  for  the  ophthalmia,  he  did  not  hesitate  to  advise  the  use 
of  bougies  for  a  couple  of  hours  a  day,  as  the  surest  and  speediest 


313 

way  of  curing  the  ophthalmia ;  and  he  tells  us,  that  he  had  the 
satisfaction  of  seeing  most  of  such  cases  cured  even  without  any 
other  external  application.* 

Case  2.  A  sailor  used  all  his  influence  to  get  appointed  to  the 
command  of  a  frigate.  He  waited  on  the  Admiralty  frequently, 
and  was  promised  a  ship  ;  and  in  the  meantime  he  went  into  Scot- 
land grouse-shooting.  Whilst  there,  he  received  instructions  from 
the  Admiralty  to  take  the  command  of  a  frigate  then  lying  at  Fal- 
mouth ;  he  lost  no  time  in  setting  out,  but  placed  himself  in  the 
mail-coach  for  London.  Just  before  he  left  Edinburgh,  he  had 
caught  a  gonorrhoea.  On  the  journey,  his  eyes  became  inflamed  ; 
and  when  he  reached  London,  he  had  a  violent  ophthalmia,  with 
purulent  discharge.  He  was  in  a  dreadful  state  both  of  body  and 
mind,  could  not  bear  the  light,  and  had  great  pain  in  the  eyes. 
Mr.  Abernethy,  whom  he  consulted,  asked  him  if  ever  he  had  had 
gonorrhoea  or  inflamed  eyes  before.  He  answered,  that  he  had  had 
both  the  one  and  the  other  ;  and  that  when  the  discharge  from  his 
urethra  was  stopped,  the  eyes  become  bad,  and  when  his  eyes  got 
well,  the  gonorrhoea  returned.  Mr.  A.  directed  him  to  remain 
quiet  in  a  darkened  room,  to  wash  his  eyes  frequently  in  the  course 
of  the  day  with  tepid  poppy  water,  to  take  five  grains  of  the  blue  pill 
every  night,  with  some  castor  oil  to  open  the  bowels,  and  to  keep 
himself  upon  a  strictly  spare  diet.  During  the  first  six  days,  he 
mended  very  slowly,  and  not  considerably.  But  on  the  seventh 
day,  when  Mr.  A.  called,  he  found  the  patient  sitting  up  in  his 
room,  the  window  uncovered,  and  his  eyes  almost  well.  Mr.  A. 
expressed  his  surprise,  and  asked  how  this  change  had  so  suddenly 
happened,  to  which  he  answered,  that  he  had  had  a  number  of 
very  copious  foetid  stools  in  the  night,  and  that  his  complaints 
had  left  him.  It  seemed  to  be  a  sort  of  critical  secretion  from 
the  liver  and  the  whole  of  the  alimentary  canal,  followed  by  an 
almost  immediate  removal  of  the  irritable  inflammation  of  the 
eyes. 

Mr.  Abernethy,  in  his  Surgical  Lectures,  spoke  of  such  cases  as 
the  above,  as  examples  of  an  irritable  ophthalmia  attendant  on 
gonorrhoea,  very  different  from  the  purulent  ophthalmia  excited  by 
touching  the  eye  with  the  matter  from  the  urethra,  and  in  fact  a 
constitutional  malady.  He  stated  that  he  had  seen  many  cases  of 
both  diseases  ;  that  he  had  known  many  people  who  were  liable 
to  rheumatism  of  the  joints,  to  puriform  discharges  from  the  urethra, 
and  to  this  irritable  ophthalmia  ;  and  that  these  diseases  used  to 
alternate  the  one  with  the  other.  When  the  rheumatism  ceased, 
the  discharge  returned  from  the  urethra,  and  when  the  discharge 
from  the  urethra  ceased,  the  affection  of  the  eye  returned,  and  thus 
one  disease  supervened  upon  another.  He  stated  that  if  the  sur- 
geon is  frightened  at  this  irritable  ophthalmia,  supposing  it  to  be  one 

•  Treatise  on  Syphilitic  Diseases,  p.  247. 

40  ' 


314 

of  the  dreadful  cases  in  which  the  eye  is  clapped,  and  proceeds  to 
bleed  and  purge  the  patient  severely,  he  will  only  make  the  matter 
worse.  Moderate  bleeding,  he  said,  may  be  useful,  but  the  chief 
object  is  to  attend  to  the  patient's  general  health.  No  means  are 
so  likely  to  be  useful  as  setting  the  digestive  organs  to  rights,  and 
sending  the  patient  to  the  country.* 

Case  3.    Major  ,  aged  25,  contracted  gonorrhosa  in  July 

1809.  In  about  a  fortnight  after  the  appearance  of  the  disease,  he 
was  seized  with  the  usual  symptoms  of  hernia  humoralis.  As 
these  abated,  pain  and  swelling  commenced  in  the  right  knee,  and 
being  at  this  time  under  the  necessity  of  travelling  in  an  open  car- 
riage for  a  couple  of  days,  at  the  end  of  the  journey  the  pain  and 
swelling  had  extended  to  the  other  knee,  and  to  the  foot  and  toes, 
especially  the  articulation  of  the  great  toe.  Suffering  under  excru- 
ciating pain,  and  wholly  deprived  of  the  use  of  his  limbs,  he  came 
under  the  care  of  Sir  Henry  Halford  :  but  no  treatment  seemed  to 
possess  any  power  in  removing  the  complaint ;  and,  in  addition, 
his  right  eye  was  suddenly  attacked  by  a  very  violent  inflamma- 
tion, which  threatened  destruction  to  the  organ.  Having  given  up 
the  use  of  medicine,  he  went  to  the  country  for  the  restoration  of  his 
health,  and  after  being  there  three  weeks,  the  gonorrhoea  again  in- 
creased without  any  abatement  of  the  other  symptoms.  The 
swelling  and  stiffness  of  the  joints  rendered  him  scarcely  able  to 
crawl  without  assistance.  The  use  of  the  warm  bath  and  a  resi- 
dence by  the  sea  were  recommended.  From  the  former,  he  expe- 
rienced little  apparent  benefit,  but  after  a  very  tedious  convalescence 
of  two  years,  he  found  himself  able  to  join  his  regiment  in  Spain. 
From  this  time  he  recovered  the  wonted  use  of  his  limbs,  and  ex- 
perienced no  return  of  his  complaint,  though  exposed  to  all  the 
hardships  of  the  campaign  of  1812.  After  exposure  to  a  current  of 
air  when  in  a  state  of  perspiration,  he  was  seized  with  an  inter- 
mittent fever,  and  obliged  to  return  to  England.  At  this  time  he 
had  some  increase  of  the  stiffness  of  his  joints.  He  continued  to 
suffer  from  ague,  and  an  impaired  state  of  health,  for  nearly  twelve 
months,  when  he  returned  to  the  active  duties  of  his  profession,  arid 
for  some  time  enjoyed  perfect  health,  and  the  free  use  of  all  his 
joints,  till  December  1814,  when  he  again  contracted  gonorrhoea, 
with  symptoms  of  unusual  violence.  In  a  fortnight  the  discharge 
began  to  abate,  and  violent  pain  with  swelling  attacked  the  great 
toe,  and  metatarsal  ligaments  of  the  right  foot.  The  disease  then 
proceeded  to  the  knees,  with  the  same  violence  of  pain  and  swelling 
as  on  the  former  occasion.  As  the  violence  of  the  symptoms  began 
to  abate  in  the  knees,  the  left  eye  was  attacked  by  violent  ophthal- 
mia, and  excited  great  alarm  for  its  safety. 

Dr.  Vetch  saw  this  patient  in  his  convalescence  from  both  the 
attacks  of  ophthalmia.     The  last  inflammation  of  the  eye  appeared 

*  Lectures  in  the  Lancet.    Vol.  \i\.  p.  5.    London,  1825. 


315 

to  have  had  its  seat  in  the  sclerotic  coat,  and  on  examining  it  more 
closely,  Dr.  V.  found  an  irregular  and  contracted  pupil,  with  some 
opacity  of  the  capsule  of  the  lens,  and  adhesion  between  it  and  the 
iris.  On  causing  him  to  shut  the  sound  eye,  the  vision  of  the  left 
was  found  very  much  impaired.  Under  the  use  of  belladonna,  and 
the|muriate  of  mercury,  the  eye  ultimately  recovered  beyond  what 
Dr.  V.  had  encouraged  the  patient  to  expect.  Great  thickening  of 
the  synovial  membrane  of  the  knee-joints  remained  in  1816,  and 
the  patient  was  still  incapable  of  standing  or  walking.  The  urethra 
continued  subject  to  returns  of  gonorrhoeal  discharge.* 

The  following  particulars  of  this  case  are  deserving  of  attention. 
On  the  first  attack  of  ophthalmia  the  right  eye  was  the  seat  of  the 
disease,  on  the  second  the  left ;  in  neither  was  there  any  symptom 
of  purulency  or  chemosis,  to  indicate  disease  of  the  conjunctiva ; 
the  disease  in  the  urethra  was  neither  suppressed  nor  modified  by 
the  attacks  of  ophthalmia ;  the  last  attack  was  decidedly  one  of 
rheumatic  inflammation|of  the  sclerotic  coat  and  iris;  an  event  (Dr. 
Vetch  thinks)  of  more  frequent  occurrence,  though  more  liable  to 
be  overlooked,  in  connexion  with  gonorrhoea,  than  purulent  inflam- 
mation of  the  conjunctiva. 

The  three  cases  above  quoted,  with  the  remarks  subjoined  to 
them  by  their  different  narrators,  will  serve  sufficiently  to  show  the 
diversity  which  exists  in  the  opinions  entertained  regarding  the 
ophthalmiee  which  in  some  individuals  are  found  to  attend  gonor- 
rhoea, or  to  alternate  with  this  disease.  It  is  quite  evident  that  the 
ophthalmiee  which  have  been  observed  to  do  so  are  far  from  being 
uniform.  That  observed  by  Swediaur  appears  to  have  been  little 
more  than  ophthalmia  tarsi ;  that  which  occurred  in  Mr.  Aberne- 
thy's  case  bears  a  strong  resemblance  to  catarrhal  ophthalmia,  and 
probably  was  nothing  more ;  while  Dr.  Yetch's  patient  evidently 
suffered  from  rheumatic  sclerotitis  and  iritis.  As  it  is  acknow- 
ledged that  in  none  of  these  cases  was  there  either  inoculation  or 
metastasis,  it  may  fairly  be  doubted  whether  there  was  any  con- 
nexion between  the  disease  of  the  urethra  and  that  of  the  eye,  far- 
ther than  that  they  occurred  in  the  same  individuals,  while  the 
occurrence  of  both  might  be  attributed  to  a  susceptibility  for  disease 
arising  from  peculiar  or  from  debilitated  constitutions. 

A  succession  of  diseases  in  the  same  individual,  recurring  from 
time  to  time  in  nearly  a  regular  order,  and  affecting  distant  and 
differently  organized  parts  of  the  body,  is  by  no  means  an  un- 
com^non  occurrence  ;  and  must  not  rashly  be  considered  as  a  proof 
tiiat  there  is  either  a  connexion  between  the  different  morbid  af- 
fections which  are  found  to  succeed  each  other,  or  a  similarity  in 
their  nature.  Dr.  Vetch's  notion  of  gonorrhoea  being  sometimes 
rheumatic,  and  of  rheumatic  ophthalmia  being  sometimes  gonor- 
rhoeal, which  he  has  adopted  from  having  met  with  gonorrhoea, 

*  Vetch's  Practical  Treatise  on  the  Diseases  of  the  Eye,  p,  243.    London,  1820. 


316 

rheumatism,  and  iritis  in  succession  in  the  same  patient,  is  a  good 
example  of  hasty  geuerahzation  in  regard  to  diseases  between 
which  no  other  relation  than  that  of  concurrence  has  been  pointed 
out. 

It  may  still  be  true,  however,  that  a  relation  may  occasionally 
exist  between  inflammations  of  the  urethra  and  inflammations  of 
the  eye,  and  that  these  diseases  may  sometimes  be  convertible,  in- 
dependently of  metastasis,  although  the  kind  of  relation  and  the 
mechanism  of  the  conversion  are  altogether  unknown. 

I  do  not  see  that  we  are  to  gain  any  thing  by  adopting  the 
name  of  irritable  ophthalmia,  bestowed  by  Mr.  Abernethy  on  the 
disease  which  he  has  observed  to  attend  gonorrhoea. 

Swediaur's  hint,  to  employ  the  bougie,  in  cases  of  ophthalmia 
alternating  with  gonorrhoea,  may  probably  be  found  of  use  ;  it  is 
evident,  however,  that  this  remedy  cannot  be  trusted  to  alone,  but 
that  the  ophthalmia  must  be  treated  according  to  the  particular 
symptoms  it  presents,  not  according  to  the  conjectural  notions  en- 
tertained regarding  its  origin.  In  such  a  case  as  Mr.  Abernethy's, 
anti-catarrhal,  and  in  such  a  case  as  Dr.  Yetch's,  anti-rheumatic 
remedies  would  be  required. 


SECTION    IX. SCROFULOUS    OPHTHALMIA. 

Scrofulous  ophthalmia  is  distinguished  from  all  the  other  in- 
flammations of  the  eye  by  symptoms  so  very  striking,  that  any  one 
who  has  seen  the  disease  once  or  twice,  cannot  mistake  it,  even 
although  the  general  habit  of  the  patient  be  concealed  from  him. 
Shght  redness,  great  intolerance  of  light,  pimples  or  small  pustules 
on  the  conjunctiva,  and  specks  on  the  cornea,  resulting  from  these 
pimples,  are  the  symptoms  which  characterize  this  ophthalmia ;  a 
disease  to  which  scrofulous  children  are  so  liable,  that  out  of  the 
100,  90  cases  of  inflammation  of  the  eyes  in  young  subjects  are 
of  this  kind.  It  is  very  often  the  first  manifestation  of  a  scrofulous 
constitution ;  and,  neglected  or  mistreated,  becomes  the  frequent 
source  of  permanently  impaired  vision,  or  even  of  entire  loss  of 
sight.  This  disease  seldom  attacks  infants  at  the  breast ;  from 
the  time  of  weaning  till  about  8  years  of  age,  is  the  period  of  life 
during  which  it  is  most  prevalent.  Sometimes  only  one  eye  is 
attacked  ;  at  other  times,  both  are  affected  from  the  first.  Not  un- 
frequently,  the  disease  passes  from  the  one  eye  to  the  other. 
When  both  are  inflamed  at  once,  the  one  is  generally  much  worse 
than  the  other. 

Symptoms. — 1.  Redness.  At  the  commencement  of  the  dis- 
ease the  redness  of  the  conjunctiva  is  very  slight.  It  often  exists 
only  on  the  inside  of  the  lids.  Sometimes  a  few  scattered  vessels 
are  seen  coursing  through  the  conjunctiva  towards  the  cornea  ;  in 
other  cases,  no  enlarged  vessels  are  perceived,  so  that  the  disease 


317 

in  this  incipient  stage,  is  distinguished  more  by  intolerance  of  light 
than  by  any  direct  signs  of  inflammation.  In  most  cases  three  or 
four  enlarged  vessels  are  discovered,  running  from  either  angle 
towards  the  cornea,  or  over  its  edge  towards  its  centre.  They 
are  evidently  superficial,  and  even  project  above  the  level  of  the 
conjunctiva.  Not  unfrequently  they  form  a  considerable  fascicu- 
lus ;  and  we  know  from  abundant  experience  of  this  disease,  that 
at  the  end  of  such  a  cluster  of  vessels,  a  pimple  is  very  likely  to  ap- 
pear, if  already  there  does  not  exist  something  of  that  sort  too 
small  as  yet  to  attract  notice.  Although  in  by  far  the  greater 
number  of  cases,  the  redness  is  scattered,  it  sometimes  happens  that 
it  is  JDretty  general  over  the  conjunctiva,  even  from  the  first.  As 
the  disease  advances,  the  redness  becomes  increased,  and  the  scle- 
rotica also  appears  somewhat  inflamed. 

.  2.  Pustules- — Ulcers — Protrusions— Specks.  This  ophthal- 
mia is  an  eruptive  disease.  It  affects  the  conjunctiva,  not  as  a  mu- 
cous m.embrane,  but  as  a  continuation  of  skin  over  the  eye.  One 
of  the  most  remarkable  symptoms  of  the  disease  is,  that  at  the 
apex  of  each  of  the  bundles  of  blood-vessels,  there  arises  one  or 
more  phlyctenulse  or  minute  pustules.  In  many  instances,  a 
single  minute  elevated  point,  of  an  opaque  white  colour,  near  the 
centre  of  the  cornea,  is  all  that  is  to  be  seen  of  this  kind  ;  in  other 
cases,  numerous  pustules  or  phlyctenulse  are  scattered  over  different 
parts  of  the  conjunctiva,  some  on  th€  cornea,  and  others  over  the 
sclerotica.  The  edge  of  the  cornea  is  a  very  common  situation 
for  them.  They  vary  in  size  according  to  the  part  of  the  conjunc- 
tiva in  which  they  appear,  being  commonly  smallest  on  the  cornea. 
Beer  has  particularly  mentioned  phlyct^nulse  as  distinguished 
from  pustules  in  this  eruptive  ophthalmia.  We  unquestionably 
meet  with  pimples  of  different  sizes  in  this  disease.  Some  patients 
have  them  all  small  like  what  are  termed  phlyctenulse,  and  others 
have  them  all  large  like  pustules.  The  former  contain  a  smaller 
quantity  of  fluid,  and  that  thin  and  colourless.  The  fluid  contained 
in  the  latter  is  greater  in  quantity  and  more  like  pus.  I  have 
not  been  able  to  decide  whether  there  is  any  specific  difference  be- 
tween the  phlyctenular  and  the  pustular  cases.  I  have  frequently 
observed  that  the  pustular  cases  are  not,  in  general,  attended  with 
so  much  intolerance  of  light.  The  cases  in  which  children  lie  for 
weeks  and  months  with  their  eyes  shut,  are  phlyctenular.  The 
pustular  variety  certainly  does  not  differ  from  the  phlyctenular 
merely  in  the  inflammatory  action  being  more  severe  in  the  former ; 
for  v/e  meet  with  cases  of  very  large  pustules,  in  which  the  inflam- 
mation and  pain  are  moderate,  compared  to  what  attend  some  cases 
of  phlyctenulse.  The  ulcer  which  succeeds  to  phlyctenula  is  some- 
times superficial,  but  at  other  times  it  grows  deep,  and  penetrates 
into  the  substance,  or  even  through  the  cornea,  so  that  no  distinc- 
tion can  be  grounded  on  the  kind  of  ulcer  which  follows  the  burst- 
ing of  these  pimples. 


318 

The  phlyctenulee  and  pustules  which  occur  in  scrofulous  ophthal- 
mia may  be  absorbed ;  and  then,  if  situated  on  the  cornea,  they  leave 
a  Uttle  albugo,  the  effect  of  that  effusion  of  coagulable  lymph  which 
surrounds  every  circumscribed  abscess,  but  which  will,  in  general, 
be  totally  removed  by  absorption  in  the  course  of  time.  Occasionally 
it  happens,  that  after  an  albugo  is  removed  by  absorption,  a  trans- 
parent dimple  is  left  in  the  cornea,  which  is  long  of  filling  up.  In 
some  cases,  we  see  the  albugo  begin  to  spread  over  the  cornea  in  an 
irregular  manner ;  pretty  considerable  red  vessels  running  into  it, 
and  additional  lymph  being  supplied  to  it,  so  as  to  form  what  I  call 
vascular  speck,  which  is  a  very  tedious  and  troublesome  symp- 
tom. 

Fully  as  often,  these  pimples  burst,  and  become  small  ulcers, 
sometimes  superficial  and  considerable  in  extent,  more  frequently 
deep  and  funnel-shaped.  This  forms  one  of  the  most  distressing 
and  formidable  symptoms  of  the  disease.  Over  the  sclerotica,  in- 
deed, an  ulcer,  arising  from  the  rupture  of  a  phlyctenula,  or  pustule, 
is  of  less  consequence,  but,  on  the  cornea,  the  transparent  inlet  of 
hght,  an  ulcer  of  any  description  is  an  event  exceedingly  to  be  de- 
precated. It  is  very  apt  to  disfigure  the  eye ;  and  by  the  opaque 
cicatrice,  which  it  leaves  behind,  permanently  to  obscure  vision. 

The  formation  of  an  ulcer,  especially  if  it  be  situated  on  the  cor- 
nea, always  produces  an  increase  of  pain  and  redness ;  the  pain 
being  greatly  aggravated  on  any  attempt  to  move  the  eye,  and 
accompanied  by  a  gush  of  hot  tears. 

The  ulcer  produced  by  a  pustule  is  apt  to  become  surrounded  by 
a  soft  reddish  edge,  easily  excited  to  bleed,  especially  if  situated  in 
the  loose  conjunctiva  over  the  sclerotica ;  but  on  the  cornea,  the 
edge  of  the  ulcer  is  sharper  and  more  abrupt,  and  the  surface,  of  a 
gray  or  ash  colour,  is  frequently  covered  with  an  adhesive  floculent 
matter.  It  but  too  often  happens  that  this  kind  of  ulcer  is  permitted, 
by  neglect  or  mismanagement,  to  penetrate  gradually  through  the 
whole  of  the  laminae  of  the  cornea,  into  the  anterior  chamber. 
Through  the  little  fistulous  opening  of  the  cornea  thus  formed,  the 
aqueous  humour  is  discharged,  and  a  small  portion  of  the  iris  pro- 
truding, looks  not  unlike  the  head  of  a  fly.  Hence  this  symptom 
is  termed  myo-cephalon.  This  piece  of  iris  unites,  by  adhesive  in- 
flammation, to  the  opening  through  which  it  is  prolapsed,  the  ulcer 
around  it  gradually  contracts  and  whitens  at  the  edge,  the  protruded 
portion  of  iris  disappears,  and  a  white  indehble  cicatrice  of  the  cor- 
nea partially  or  entirely  prevents  vision,  A  cicatrice  of  the  cornea 
is  called  a  leucoma,  in  contradistinction  to  albugo ;  the  latter  opacity 
being  the  result  of  effusion,  not  of  ulceration.  If  the  ulcer  has  ex- 
tended deep  into  the  substance  of  the  cornea,  and  much  more  if  it 
has  penetrated  through  it  completely,  the  leucoma  which  follows 
remains  for  Mfe,  although  in  the  progress  of  growth,  and  after  a 
length  of  time,  it  may  contract  considerably.  The  cicatrice  result- 
ing from  a  superficial  ulcer  may  entirely  disappear.     Indeed,  the 


319 

cicatrice  from  a  superficial  ulcer  is  sometimes  transparent  from  the 
first. 

If  several  pustules  form  on  the  cornea  at  the  same  time,  it  some- 
times happens  that  they  unite  with  one  another  before  they  burst, 
so  that  the  purulent  matter  is  infiltrated  between  the  lamellae,  and 
thus  a  kind  of  onyx  is  formed.  At  other  times,  onyx  appears  at 
the  lower  edge  of  the  cornea,  independently  of  the  existence  of 
pustules. 

In  some  cases  of  ulcer  of  the  cornea,  the  progress  of  the  ulcer 
is  unimpeded  till  the  whole  thickness  of  the  cornea  is  penetrated, 
except  the  lining  membrane ;  which  seems  to  arrest  the  ulcerative 
process,  but  being  unable  to  withstand  the  push  made  by  the 
aqueous  humour,  is  projected  through  the  ulcer  in  the  form  of  a 
small  vesicle.  This  is  what  is  called  hernia  cornea..  At  last  this 
vesicular  protrusion  gives  way,  the  aqueous  humour  escapes,  pro- 
lapsus of  the  iris  follows,  and  a  dense  opaque  cicatrice  will  be  the 
result. 

Where  there  has  been  an  extensive  prolapsus  of  the  iris,  through 
an  ulcer  of  the  cornea,  the  pseudo-cornea  which  is  formed  over  the 
protruded  portion  of  iris,  is  sometimes  unable  to  withstand  the  pres- 
sure of  the  aqueous  humour,  but  is  pressed  forwards  so  as  to  form 
a  partial  staphyloma. 

3.  Pain — Intolerance  of  light — Epiphora.  The  excessive 
intolerance  of  hght  which  in  general  attends  scrofulous  ophthalmia 
is  one  of  the  most  striking  and  distressing  symptoms  of  the  disease. 
The  child  (for  children  are  the  usual  subjects  of  this  disease)  is 
quite  unable  to  open  the  eyes  in  the  ordinary  light  of  day,  or  by 
any  act  of  volition  to  expose  them  so  as  to  permit  a  satisfactory 
examination  of  their  state ;  all  his  attempts  to  look  up  are  instan- 
taneously interrupted  by  strong  spasmodic  contraction  of  the  eye- 
lids ;  for  whole  days,  weeks,  or  even  months,  a  child  affected  with 
this  disease  will  lie  on  his  face  in  bed ;  or,  if  forced  out  of  bed,  he 
will  stand  pressing  his  eyes  against  his  arm,  and  no  persuasion 
will  bring  him  to  lift  up  his  head  or  look  at  the  light.  The  in- 
tolerance of  light  is  always  most  severe  in  the  morning.  In  the 
afternoon  it  sometimes  remits  so  much,  as  to  allow  the  patient  to 
open  his  eyes,  and  see  to  a  very  considerable  degree,  for  some  hours. 

It  might  perhaps  be  supposed  that  this  excessive  intolerance  of 
light  and  spasmodic  contraction  of  the  orbicularis  palpebrarum 
should  attend  only  the  worst  cases,  or  where  there  was  a  great 
degree  of  inflammation.  But  it  is  not  so.  The  mother  or  the 
nurse  taking  up  the  child,  lays  it  across  her  lap,  while  the  surgeon, 
receiving  the  head  firmly  between  his  knees,  and  laying  hold  of 
the  eyelids,  without  suffering  the  conjunctiva  to  become  everted  or 
protruded,  raises  the  upper  eyelid,  so  as  to  expose  the  sclerotica ; 
the  cornea  is  turned  up  out  of  view,  and  it  requires  considerable 
management  to  elevate  the  upper  lid  so  as  ta  expose  the  cornea 
completely.     But  still  this  may  be  done,  and  before  any  prognosis 


320 

ean  be  g-iveri,  must  be  done.  In  many  cases,  we  are  astonished; 
when  we  thus  examine  the  eye,  to  find  only  a  very  insignificant 
degree  of  redness,  not  more  than  we  should  find  were  we  to  ex- 
amine a  healthy  eye  in  the  same  way,  the  cornea  often  perfectly 
transparent  and  entire,  or  perhaps  a  single  minute  spot  of  opacity 
on  the  cornea,  with  a  few  red  vessels  running  over  the  sclerotica. 
The  excessive  intolerance  of  light  exists  in  many  cases  almost 
alone.  It  is  worthy  of  remark,  that  in  many  of  the  cases  in  which 
we  find  large  pustules  on  the  conjunctiva  covering  the  sclerotica, 
the  intolerance  of  light  is  not  nearly  so  intense,  as  in  cases  where 
the  eruption  is  more  of  the  plilyctenular  sort,  or  even  where  there 
is  as  yet  no  sort  of  pimple  formed. 

The  intolerance  of  light  in  this  disease  is  always  attended  with 
epiphora,  and  often  by  violent  fits  of  sneezing.  Whenever  the 
patient  voluntarily  attempts  to  open  the  eye,  or  whenever  we  forci- 
bly expose  it,  a  gush  of  tears  succeeds  ;  the  eye  is  thereby  reddened, 
the  eyelids  swell,  and  if  the  exposure  is  repeated  from  time  to  time, 
the  cheek  becomes  chafed  and  excoriated.  A  pustular  eruption 
rises  upon  the  face  from  the  irritation  of  the  tears,  and  the  cheek 
sometimes  becomes  exceedingly  swoln,  red,  and  painful,  from  the 
same  cause. 

There  does  not  appear  to  be  in  general  any  very  great  degree 
of  absolute  or  inflammatory  pain  attendant  on  strumous  ophthal- 
mia, not  even  when  the  patient  attempts  to  open  the  eye.  If  we 
let  the  child  alone,  he  will  lie  all  day  in  some  dark  corner  of  the 
room,  without  complaining  much  of  pain.  But  so  excessively  dis- 
agreeable to  him  is  the  least  access  of  light,  that  he  will  rather 
forego  all  his  little  amusements,  both  within  and  out  of  doors, 
than  open  his  eyes.  It  would  appear,  however,  that  it  is  not  so 
much  absolute  pain  which  is  excited,  as  a  sensation  similar  to 
what  arises  in  the  eye  when  exposed  to  the  sun's  rays  reflected 
from  the  surface  of  a  mirror — a  sensation  of  intolerable  glare  and 
dazzling.  Pain  during  the  night,  however,  is  not  an  unfrequent 
symptom.  It  seems  to  occur  even  during  sleep,  for  the  child  often 
awakes  screaming  with  pain  in  the  eyes. 

Commonly  a  great  degree  of  itchiness  attends  this  disease,  so 
that  the  patient  rubs  the  eyelids  very  much.  There  is  also  a  feeling 
of  sand  in  the  eye,  although  not  so  remarkably  as  in  the  catarrhal 
ophthalmia. 

An  anatomical  fact,  to  which  I  have  already  had  occasion  to  re- 
fer, may  aid  us  in  accounting  for  the  extreme  intolerance  of  light, 
spasmodic  contraction  of  the  eyelids,  and  epiphora  which  accom- 
pany this  disease,  even  in  cases  where  scarcely  any  redness  is 
present ;  namely,  that  the  lachrymal  nerve,  after  supplying  the 
lachrymal  gland,  goes  to  the  conjunctiva  and  orbicularis  palpe- 
brarum, and  may  serve  to  estabhsh  a  strong  nervous  sympathy 
between  these  several  parts.  We  see  this  sympathy  called  into 
action  when  any  minute  particle  of  dust  fixes  itself  on  the  inside 


321 

of  the  upper  eyelid.  We  have  then  the  same  intolerance  of  light, 
spasm  of  the  orbicularis  palpebrarum,  and  rush  of  tears,  which  we 
meet  with  in  scrofulous  ophthalmia,  so  that  it  would  appear  that 
this  disease,  even  in  its  incipient  stage,  excites  very  much  the  same 
train  of  effects  which  follows  the  irritation  of  a  particle  of  dust  on 
the  inside  of  the  upper  eyelid. 

4.  Iritis— Ophthalmia  tarsi.  Other  local  symptoms,  besides 
those  already  enumerated,  are  often  present.  In  some  the  iris  suffers 
inflammation,  although  iritis  is  certainly  a  more  frequent  attendant 
on  corneitis  than  on  pustular  or  phlyctenular  ophthalmia.  Inflam- 
mation of  the  choroid  or  of  the  retina  is  still  more  rarely  attendant 
on  this  disease.  Very  frequently  we  find  it  combined  with  oph- 
thalmia tarsi. 

5.  Other  scrofulous  symptoms  may  be  detected  in  almost 
every  case  of  this  disease ;  as,  eruptions  about  the  head,  sore  ears, 
swelling  of  the  upper  lip,  running  from  the  nose,  excoriation  of  the 
nostrils,  enlarged  lymphatic  glands  under  the  jaw,  exostosis  of  the 
fingers,  swoln  joints,  tabes  mesenterica,  «fec.  With  some  of  these 
symptoms  w^e  often  find  the  ophthalmia  to  alternate,  being  ag- 
gravated, for  instance,  when  sore  ears  cease  to  run,  and  mending 
when  they  again  become  sore.  I  have  seen  this  ophthalmia  re- 
peatedly alternate  with  scrofulous  swelling  of  the  knee.  The  erup- 
tion on  the  scalp,  which  is  generally  met  with  along  with  scrofulous 
ophthalmia,  is  porriginous.  Not  unfrequently,  an  impetiginous 
eruption  over  the  body  is  found  to  be  present,  especially  in  children 
who  live  much  on  milk. 

6.  A  tum,id  and  hard  abdom,en,  and  disordered  boivels,  com- 
monly attend  this  disease.  The  stomach  and  bowels  appear  to 
be  loaded  with  morbid  secretions ;  and  the  evacuations  are  dark. 
The  tumidness  of  the  belly  seems  to  be  owing  in  part  to  muscular 
weakness. 

7.  There  is  considerable  general  debility,  especially  in  cases  of 
long  continuance.  The  skin  is  loose  and  flabby,  and  sometimes  a 
great  degree  of  emacitition  is  present.  The  patient  is  hot  and 
restless  in  the  early  part  of  the  night,  and  sweats  profusely  towards 
morning.  A  great  degree  of  fretfulness  is  produced  by  the  disease 
and  prolongs  its  continuance. 

Remote  or  Predisposing  Causes.  1.  The  Scrofulous  Con- 
stitution may  be  regarded  as  the  chief  remote,  or  predisposing  cause 
of  this  ophthalmia. 

That  the  scrofulous  constitution  very  powerfully  modifies  local 
diseases,  is  a  fact  which  must  excite  the  attention  of  the  most  super- 
ficial observer.  Indeed,  by  the  term  scrofula,  we  do  not  so  much 
mean  a  disease  of  any  particular  set  of  organs,  as  a  state  of  the 
whole  system,  predisposing  diflferent  parts  of  the  body  to  become 
aflfected  with  local  diseases,  and  modifying  those  local  affections 
which  may  arise  from  accidental  causes. 
41 


322 

The  description  commonly  given  of  scrofula  applies  too  exclu- 
sively to  that  form  of  the  disease  in  which  it  appears  as  an  affection 
of  the  absorbent  glands.  Considered  as  a  state  of  constitution 
influencing  the  origin  and  progress  of  local  diseases,  the  accounts 
given  of  scrofula  have  somelinjes  appeared  to  be  contradictory  to  one 
another.  These  apparent  contradictions  have  arisen  from  the 
variety  of  appearances  under  which  the  scrofulous  diathesis  presents 
itself,  and  from  its  different  effects  in  different  cases.  For  instance, 
the  scrofulous  diathesis  seems  sometimes  to  hasten  the  progress  of  a 
local  inflammatory  disease,  and  at  other  times  to  prolong  the  process 
of  inflammation.  Beer  has  distinguished  different  classes  of  scrofulous 
patients  :  and,  indeed,  it  requires  but  little  experience  of  scrofulous 
diseases  to  observe  that  those  individuals  whose  texture  throughout 
is  extremely  lax,  who  have  the  nose  and  upper  lip  almost  constantly 
swoln  and  scuify,  the  abdomen  uncommonly  distended,  and  who 
are  affected  so  frequently  with  chronic  swellings  of  tlie  lymphatic 
glands,  form  a  sub-class  sufficiently  distinct  from  the  general 
subjects  of  tubercles  in  the  lungs.  The  latter  are  lively  and 
irritable,  and  are  rarely  affected  with  the  external  lymphatic  swell- 
ings, thecrusta  lactea.  tinea  capitis,  ophthalmia  tarsi,  running  from 
the  ears,  and  diseased  joints,  to  which  the  former  sub-class  are  so 
very  liable.  Beer  asserts,  that  the  first  sub-class  are  more  subject 
to  the  pustular  variety  of  scrofulous  ophthalmia,  and  the  second 
to  the  phlyctenular ;  and  that  the  disease  is  generally  much  more 
tedious  in  the  former  than  in  the  latter.  He  tells  us  also  that 
the  intolerance  of  light  is  not  nearly  so  considerable  in  the  first 
class  as  in  the  second  ;  the  pain  not  so  acute,  the  long  continued 
spasmodic  contractions  of  the  eyelids  not  nearly  so  common  ;  the 
disease  not  at  all  so  apt  to  pass  into  iritis,  but  more  liable  to  be 
attended  by  inflammation  of  the  Meibomian  follicles,  and  this 
sometimes  passing  into  puro-mucous  conjunctivitis. 

Mr.  Wardrop  has  published,  in  the  second  volume  of  the  Edin- 
burgh Medico-Chirurgical  Transactions,  an  accountof  w-hat  he  calls 
the  exanthematous  ophthalmia,  which  seems  to  be  nothing  else 
than  the  disease  we  are  now  considering.  He  says,  indeed,  that 
the  scrofulous  ophthalmia  is  a  disease  quite  distinct  from  the  exan- 
thematous  :  but  he  neglects  to  point  out  a  single  diagnostic  symp- 
tom by  which  the  one  could  be  known  fiom  the  other,  while  his 
description  corresponds  exactly  with  that  of  scrofulous  ophthalmia 
given  by  Beer  and  others.  Mr.  W.  admits  that  persons  of  a  scrofu- 
lous constitution  are  very  subject  to  the  exantheraatous  ophtlialmia, 
"from  the  same  causes,"  he  adds,  -which  render  them  also  parti- 
cularly liable  to  many  other  diseases  ;  but  neither  the  character  of 
the  ophthahnia.;'  says  he,  '•  nor  the  eruptions  with  which  it  is  con- 
nected, are  necessarily  derived  from  a  scrofulous  diathesis,  nor  does 
the  disease  appear  in  those  alone  where  the  scrofulous  diathesis  can 
be  detected."  This  looks  hke  a  sort  of  apology  for  those  who  are 
the  subjects  of  this  disease.     Not  only  is  the  term  exanthematous, 


323 

as  applied  by  Mr.  Wardrop,  nosologically  incorrect,  but  his  assertion 
as  to  the  noti-scrofulous  nature  of  the  disease  is  unsupported  by  any 
proof,  and  the  giving  this  out  as  a  newly  distinguished  ophthahnia 
is,  I  think,  improper. 

Mr.  Christian,  of  Liverpool,  says  he  can  distinguish  the  scrofu- 
lous from  the  porriginous  ophthalmia,  and  thinks  that  the  latter  is 
excited  by  the  contact  of  porriginous  matter  carried  by  the  fingers 
of  the  child  from  the  ears  or  from  the  head  to  the  eyes.  There  is 
some  plausibility  in  this,  and  the  hint  may  very  properly  be  adopted 
of  preventing  as  much  as  possible  the  child  from  touching  any  por- 
riginous or  other  eruption  on  its  head,  and  afterwards  conveying  its 
fingers  to  the  eyes.* 

2.  Food — Air — Exercise — Clothing.  While  without  any  hesi- 
tation we  regard  the  scrofulous  constitution  as  the  chief  predisposing 
cause  of  this  ophthalmia,  we  must  not  omit  to  mention  that  other  re- 
mote causes  evidently  operate  in  its  production  ;  namely,  improper 
diet,  want  of  air  and  exercise,  and  insuthcient  clothing.  It  is  from 
the  operation  of  these  causes  that  this  ophthalmia  and  other  scrofu- 
lous diseases  are  so  frequent  in  large  and  crowded  towns,  and  pre- 
vail so  abundantly  among  the  children  of  the  poor  who  live  in  nar- 
row streets  and  alleys,  breathing  an  impure  atmosphere,  confined 
to  a  scanty  and  unnutritious  diet,  regardless  of  cleanliness,  and  ill  pro- 
tected from  changes  of  weather. 

3.  Climate.  Our  variable  climate  is  a  powerful  promoter  of 
scrofulous  ophthalmia.  In  the  south  of  Europe,  on  the  other  hand, 
for  instance  in  the  inland  paris  of  Italy,  this  disease  is  rare,  even 
among  the  poorest  of  the  people,  whose  food  is  the  least  digestible 
an.d  least  nourishing.  We  see  the  effects  of  climate  on  this  disease 
in  the  rapid  changes  which  it  undergoes  when  the  weather  becomes 
either  suddenly  cold  and  wet,  or  dry  and  warm.  All  the  symptoms 
are  greatly  aggravated  by  the  former,  and  as  remarkably  relieved 
by  the  latter.  New  attacks,  both  in  those  who  have  and  those  who 
have  not  previously  suffered  from  this  disease,  are  most  prevalent 
during  north-easterly  winds. 

Exciting  Causes.  1.  Measles^  Scarlet-fever^  and  Small-'pox 
rouse  into  activity  the  scrofulous  diathesis.  These  diseases  them- 
selves affect  the  eyes,  and  leave  these  organs  tender,  and  apt  to  fall 
into  this  ophthalmia. 

2.  Catarrhal  ophthalmia,  brought  on  in  the  common  way,  is 
extremely  apt  to  degenerate,  in  scrofulous  children,  into  the  phlyc- 
tenular or  the  pustular. 

3.  Excessive  use  of  the  eyes  on  minute  objects,  and  especi- 
ally by  candle  light,  is  often  the  exciting  cause  of  scrofulous  oph- 
thalmia. 

4.  Teething  is  a  frequent  exciting  cause. 

5.  Injuries,  as  those  produced  by  particles  of  dust  lodging  in  the 

*  Glasgow  Medical  Journal,  Vol.  i.  p.  32-    Glasgow,  1828. 


324 

folds  of  the  conjunctiva,  slight  blows,  and  the  like,  are  often  the 
occasional  causes  of  scrofulous  ophthalmia. 

Prognosis.  It  is  necessary  to  give  a  very  cautious  prognosis  in 
this  disease.  Much  depends  on  the  patient's  pursuing  the  treatment 
methodically,  not  only  till  the  cure  seems  complete,  but  for  a  con- 
siderable length  of  time  after.  JNo  disease  is  so  apt  to  relapse  as 
scrofulous  opthalmia  :  the  parents  should  be  made  aware  of  this, 
and  directed  to  make  instant  application  whenever  they  observe  a 
recurrence  of  any  of  the  symptoms. 

When  ulcers  are  present  on  the  cornea,  specks  must  necessarily 
follow.  These  will  prove  more  or  less  obstinate,  according  to  the 
depth  of  the  previous  ulceration,  and  will  impede  vision  in  propor- 
tion as  they  are  more  or  less  over  the  pupil.  Perforating  ulcer,  fol- 
lowed by  protrusion  of  the  iris,  leaves  almost  uniformly  a  dense  leu- 
coma,  wiih  deformed  pupil. 

Treatment.  We  are  obliged  to  speak  of  the  treatment  of  stru- 
mous ophthalmia  in  very  different  language  from  what  we  employ 
in  advising  remedies  for  almost  any  other  inflammatory  disease  of 
the  eye.  In  other  ophthalmiee,  we  say.  Follow  this  plan  of  treat- 
ment which  we  recommend,  and  the  disease  will  speedily  be  over- 
come. We  speak  thus  of  the  catarrhal  ophthalmia,  and  of  several 
others,  but  we  cannot  speak  in  this  way  of  the  scrofulous.  We  are 
forced  to  confess  that  in  many  cases  this  ophthalmia  proves  rebel- 
lious. If  it  be  asked  why  it  does  not  yield  even  to  the  best  directed 
treatment,  we  answer  this  question  by  proposing  another  ;  namely, 
Why  does  an  inflamed  gland  of  the  neck  in  a  scrofulous  individual 
prove  so  troublesome,  going  on  to  suppurate  in  spite  of  every  means 
adopted  to  promote  resolution,  and  after  it  has  suppurated  and 
burst,  continuing  to  discharge  for  years?  The  strumous  consti- 
tution is  the  cause  of  the  extreme  tediousness  of  this  ophthalmia, 
as  well  as  of  the  frequently  intractable  nature  of  other  strumous 
diseases  ;  and  till  we  discover  means  for  curing  scrofula,  this  oph- 
thalmia will  continue  occasionally  to  mock,  by  its  stubbornness, 
even  the  best  and  most  carefully  pursued  plan  of  cure. 

Is  it  incurable  then  'I  Are  we  to  do  nothing  for  it ;  but  shake 
our  heads,  and  leave  the  eyes  to  be  destroyed  ?  Not  at  all.  Much 
may  be  done  to  relieve  this  disease.  Although  it  is  very  difficult 
to  cure  it  thoroughly,  especially  when  the  patient  continues  exposed 
to  the  influence  of  the  same  causes  which  originally  produced  it, 
yet  it  is  rare  indeed  that  medical  treatment  does  not  moderate  the 
symptoms,  and  avert  those  changes  in  the  transparent  front  of  the 
eye,  which  in  neglected  cases  are  so  often  the  causes  of  loss  of 
sight.  But  when  the  practitioner  does  meet  with  cases,  as  some- 
times he  must  do,  which  receive  no  benefit  for  weeks  and  months, 
but  perhaps  rather  get  worse,  notwdthstandiug  all  that  is  done  for 
them,  he  must  not  blame  himself  too  much,  but  reflect  on  the  in- 
tractable diathesis  with  which,  in  such  cases,  he  is  called  to  con- 
tend, and  which  he  cannot  change,  and  but  too  often  can  scarcely 
in  the  smallest  degree  ameliorate. 


325 

In  the  treatment  of  this  disease,  it  is  necessary  constantly  to  bear 
in  mind  that  it  depends  on  a  constitutional  cause.  To  relieve  the 
local  affection,  therefore,  will  not  be  sufficient.  We  must  endea- 
vour to  improve  the  general  health. 

1.  General  Remedies.  1.  Bleeding.  General  blood-letting 
is  hardly  ever  required  ;  nor  need  local  bleeding  be  had  recourse  to, 
unless  considerable  febrile  excitement,  as  well  as  local  distress,  be 
present.  When  the  inflammatory  action  runs  higher  than  ordinary, 
or  where  it  is  suddenly  or  violently  augmented  by  the  formation  of 
pimples  or  ulcers  on  the  cornea,  it  is  proper  to  moderate  the  impetus 
of  the  blood  by  the  application  of  leeches  to  the  eyelids  or  the  tern 
pie.  If  the  constitution  is  not  as  yet  impaired  by  long  continu- 
ance of  the  disease,  and  the  employment  of  many  debilitating  rem^ 
edies,  repeated  recourse  must  be  had  to  the  use  of  leeches,  so  long 
as  the  redness  of  the  conjunctiva  is  considerable,  and  the  intoler- 
ance of  light  acute.  It  must  be  kept  in  mind,  however,  that  not 
unfrequently  we  may  dispense  with  bleeding  entirely,  by  putting 
the  patient  under  the  influence  of  tartar  emetic  ;  and  that  by  deple- 
tion alone,  no  case  of  this  disease  can  ever  be  cured.  On  the  con- 
trary, repeated  bleedings,  without  the  use  of  other  remedies,  reduce 
too  much  the  general  strength,  and  render  the  eye  more  suscepti- 
ble of  destructive  changes. 

2.  Emetics  and  nauseants.  One  of  the  most  powerful  and 
successful  methods  of  treating  scrofulous  ophthalmia  is  by  means  of 
tartar  emetic,  either  in  such  doses  as  to  produce  vomiting  ;  in  smaller 
quantities  frequently  repeated,  so  as  to  excite  nausea  ;  or  combined 
with  a  purgative.  There  is  perhaps  no  remedy  in  the  whole  ma- 
teria medica  which  possesses  equal  powers  of  a  sedative  kind  in 
this  disease.  It  reduces  very  considerably  the  necessity  of  general 
and  local  blood-letting. 

I  generally  commence  the  treatment  of  a  case  of  scrofulous  oph- 
thalmia with  an  ernetic,  either  of  ipecacuan  or  tartrate  of  antimony, 
and  with  uniform  good  effects. 

In  cases  where  there  is  considerable  quickness  of  pulse,  I  fre- 
quently put  the  patient  on  a  course  of  nauseants,  or  of  emeto-ca- 
thartics.  For  instance,  to  an  adult  a  mixture  may  be  given  of  from 
one  to  four  grains  of  tartar  emetic,  with  from  one  to  two  ounces  of 
sulphate  of  magnesia,  dissolved  in  a  pound  of  water.  Of  this  so- 
lution two  or  three  tablespoonfuls  may  be  taken  every  half  hour 
till  vomiting  is  excited  ;  after  which,  the  dose  is  to  be  repeated  at 
intervals  of  three,  four,  or  six  hours,  as  circumstances  may  require. 
This  is  the  method  to  be  followed  in  acute  cases.  In  chronic 
cases,  the  nauseant  may  be  exhiliited  at  longer  intervals.  It  may 
then  be  more  conveniently  exhibited  in  pills;  each  pill  containing 
from  a  quarter  to  half  a  grain  or  more  of  the  tartar  emetic. 

In  cases  of  children,  the  same  solution  of  tartar  emetic  and  salts 
may  be  employed,  or  a  solution  of  tartar  emetic  by  itself,  or  pow- 
ders of  the  same  rubbed  up  with  a  little  sugar.     From  the  twelfth 


326 

to  the  sixth  of  a  grain,  may  be  given  according  to  the  age  of  the 
child,  thrice  a  day.  When  there  is  much  quickness  of  pulse,  this 
plan  will  often  prove  effeclual,  while  purgatives  or  tonics  would  pro- 
duce little  or  no  good. 

3.  Purgatives.  In  children  labouring  under  strumous  ophthal- 
mia, there  is  commonly  a  full  and  hard  abdomen,  and  a  loaded 
state  of  the  stomach  and  bowels.  Even  in  feeble  and  emaciated 
children,  it  will  usually  be  found,  that,  by  the  exhibition  of  purga- 
tives, a  large  quantity  of  unnatural  foeculent  matter  will  be  dis- 
charged. In  such  cases,  the  administration  of  purgatives  is  followed 
by  marked  benefit ;  and  without  these,  other  remedies  avail  but 
little.  In  recent  cases,  a  purge  of  calomel,  wiili  jalap,  rhubarb,  or 
scammony,  will  often  be  sufficient  to  remove  the  attack  of  ophthal- 
mia altogether.  Such  a  purgative  is  to  be  repeated  at  intervals  of 
two,  three,  or  more  days,  according  to  the  urgency  of  the  symptoms. 
It  not  only  empties  the  bowels  ;  but  reduces  very  powerfully  the 
impetus  of  the  blood  in  the  affected  part,  increases  the  action  of  the 
absorbents,  and  restores  to  a  healthy  state  the  secretions  of  the  di- 
gestive organs.  It  proves,  in  short,  alterative,  as  well  as  depletive; 
and  its  use  as  such  may  be  persisted  in,  in  many  cases,  for  a  length 
of  time,  with  very  decided  benefit.  I  have  found  the  purgative 
plan  to  be  more  useful  than  any  other,  in  those  cases  in  which  an 
impetiginous  eruption  over  the  body  accompanies  the  affection  of 
the  eyes.  Care,  however,  must  be  taken  not  to  push  its  debilitating 
action  too  far. 

4.  Tonics.  There  are  several  remedies  of  this  class,  which 
prove  strikingly  beneficial  in  the  treatment  of  scrofulous  oph- 
thalmia. 

After  a  trial  of  numerous  and  various  internal  remedies  in  this 
disease,  I  have  found  none  so  useful  as  the  sulphate  of  quina.  It 
exercises  a  remarkable  power  over  the  constitutional  disorder  which 
attends  this  ophihahnia,  and  thereby  over  the  local  complaint. 
The  dose  which  I  employ  is  generally  a  grain  thrice  a  day,  rubbed 
up  with  a  little  sugar;  in  ver}^  young  children,  half  a  grain  :  and 
in  adolescents  or  adults,  two  grains.  Cinchona  is  not  a  nev.'  rem- 
edy in  this  ophthalmia.  Dr.  Fothergill  recommended  it  many 
years  ago  in  very  strong  terms  ;*  but  its  povvers,  in  the  form  of 
powdered  bark,  or  in  any  other  form  in  which  [  have  tried  it,  are 
insignificant  in  comparison  to  those  of  the  sulphate  of  quina.  In 
most  instances,  its  effects  are  very  remarkable ;  and,  indeed,  (al- 
though I  have  met  with  a  iew  case?  which  appeared  to  resist  its 
beneficial  influence),  in  most  of  the  little  paiients  to  whom  I  have 
administered  it,  it  has  acted  like  a  chai'm  ;  abating,  commonl3nn  a 
few  days,  the  excessive  intolerance  of  light  and  profuse  epiphora, 
promoting  the  absorption  of  pustules,  and  hastening  the  cicatriza- 

*  Medical  Observations  and  luquiries,  Vol.  i,  p.  303.  London,  1763.  Also,  Dr. 
Fordyce,  in  same  Vol.  p.  192.  Dr.  Fothergill  used  a  decoction  of  the  powdered  bark, 
with  liquorice  root. 


327 

tion  of  ulcers  of  the  cornea.  The  use  of  this  medicine  may  be  be- 
gun as  soon  as  the  stomach  has  been  cleared  by  an  emetic,  and  the 
bowels  put  to  rights  by  repeated  doses  of  calomel  with  rhubarb,  or 
some  other  sucii  purgative,  unless  the  pulse  is  very  quick,  when 
small  doses  of  tartar  emetic  will  be  preferable,  or  when  an  impeti- 
ginous eruption  is  observed  on  the  surface  of  the  body,  in  winch 
case  a  course  of  purgatives  ought  to  be  adopted. 

I  cannot  forbear  quoting  from  the  Journals  of  the  Eye  Infirmary 
the  two  following  cases,  iUustrative  of  the  good  effects  of  sulphate  of 
quina. 

Case  1.  Jane  Thomson,  aged  9,  was  admitted  on  the  23d  of 
July,  1828,  with  strumous  ophthalmia  of  the  right  eye,  of  fourteen 
days'  standing.  There  was  a  deep  ulcer  near  the  centre  of  the 
cornea,  surrounded  by  a  broad  effusion  of  lymph  ;  and  there  was 
an  onyx  at  the  lower  edge  of  the  cornea.  She  was  affected  with 
night  sweats,  and  was  much  reduced  in  general  health  by  bleeding, 
purging,  and  blistering.  She  was  ordered  to  take  three  grains  of 
quina  daily,  a  drop  of  the  nitras  argenti  solution  was  applied  to  the 
eye,  and  she  had  the  murias  hydrargyri  collyrium.  On  the  24th, 
the  onyx  was  all  but  gone.  On  the  27th,  tiie  ulcer  was  reported 
as  contracted.  On  the  29th,  on  account  of  an  attack  of  bowel 
complaint,  she  was  ordered  two  grains  of  calomel  with  a  quarter  of 
a  grain  of  opium  at  bedtime.  After  this  the  case  continued  steadily 
to  improve,  the  ulcer  cicatrized,  the  eye  became  strong,  and  the  leu- 
coma  grew  thin.  In  all  probability,  the  cornea  would  speedily  have 
been  penetrated  by  the  ulcer,  if  the  depletory  system  had  been  per- 
sisted in,  w4iich  this  patient  was  undergoing  before  she  came  to  the 
Eye  Infirmary.  Within  24  hours,  the  sulphate  of  quina  had  evi- 
dently arrested  the  progress  of  the  disease. 

Case  2.  James  Tassie,  aged  8,  was  admitted  on  the  1 5th  of 
August,  1828,  with  strumous  ophthalmia  of  the  right  eye.  He  had 
been  troubled  with  this  complaint,  more  or  less,  for  seven  years. 
There  was  formerly  a  considerable  albugo  on  the  right  cornea,  but 
it  had  diminished  much  till  within  a  fortnight  before  his  admission, 
when  a  relapse  took  place.  The  cornea  appeared  to  be  rough  and 
nebulous,  but  the  intolerance  of  light  was  so  great  that  it  was  with 
difficulty  that  any  part  of  it  could  be  exposed.  The  nitras  argenti 
solution  was  applied,  and  he  had  a  solution  of  tartar  emetic,  in  di- 
vided doses,  till  vomiting  v\^as  produced. 

Next  day  he  could  open  the  eye  better,  and  an  onyx  was  now 
observed  at  the  lower  edge  of  the  cornea,  which  had  not  been  per- 
ceived on  (he  previous  day.  He  was  ordered  to  take  a  grain  of 
sulphate  of  quina  thrice  a  day,  and  to  use  the  murias  hydrargyri 
collyrium.  By  the  18th,  the  onyx  was  gone.  The  extract  of  bel- 
ladonna was  applied  to  the  eyebrow  and  forehead,  some  fears  being 
entertained  regarding  the  state  of  the  iris.  By  the  20th,  the  intol- 
erance of  light  having  considerably  subsided,  the  cornea  could  be 
more  completely  seen..    The  centre  of  it  was  found  to  be  perforated 


328 

by  an  ulcer,  and  the  pupil  contracted.  On  the  22d,  the  eye  con- 
tinued easier,  but  the  iris  was  observed  to  be  every  where  in  con- 
tact with  the  cornea.  The  sulphate  of  quina,  belladonna,  and 
collyriuni,  were  continued.  On  the  27th,  the  iris,  appeared  to  be 
returning  a  little  into  its  natural  place,  the  pupil  was  pretty  visible, 
and  he  saw  a  little  with  the  eye.  On  the  28th,  the  pupil  was  evi- 
dently expanding  and  tiie  cornea  clearing.  By  the  1st  of  Septem- 
ber, the  pupil  was  free  of  the  cornea,  except  at  its  inner  edge, 
Avhere  it  still  adhered  by  a  single  point.  By  the  16th,  the  iris  was 
entirely  free.  Soon  after  this,  the  ulcer  of  the  cornea  cicatrized, 
the  speck  gradually  cleared,  and  the  eye  retained  a  very  considera- 
ble share  of  vision.  This  was  one  of  the  most  remarkable  and 
pleasing  recoveries  from  penetrating  ulcer  of  the  cornea,  and  in- 
volved iris,  which  I  have  met  with.  The  recovery  w^as  mainly- 
attributable  to  the  salutary  operation  of  the  sulphate  of  quina  on 
the  inflammatory  affection,  and  to  the  mechanical  effect  produced 
by  the  belladonna. 

The  chalybeates  stand  next  to  the  sulphate  of  quina  among  the 
tonic  medicines  worthy  of  confidence  in  the  treatment  of  scrofulous 
ophthalmia.  The  precipitated  carbonate  of  iron,  and  the  tartrate 
of  potass  and  iron,  are  the  forms  which  I  have  found  most  useful. 
They  are  more  effectual,  however,  in  the  pustular  than  in  the 
phlyctenular  variety  of  this  ophthalmia. 

An  excellent  tonic  and  laxative  remedy  in  this  disease  is  the 
common  combination  of  rhubarb  and  supercarbonate  of  soda. 

The  mineral  acids,  and  especially  the  sulphuric,  will  also  be 
found  useful. 

We  may  set  down  the  cold  bath  as  a  very  efficient  tonic  in  scro- 
fulous ophthalmia  :  but  it  is  not  to  be  employed  till  after  the  acute 
symptoms  h  ive  subsided.  At  an  earlier  period,  the  tepid  bath  will 
prove  soothing  and  refreshing,  and  ought  to  be  frequently  em- 
ployed. 

The  employment  of  tonics,  both  medical  and  dietetical,  must  be 
continued  long  after  all  the  inflammatory  sym.ptoms  have  disap- 
peared, in  order,  if  possible,  to  communicate  to  the  constitution  that 
degree  of  vigour,  which  may  enable  it  to  resist  any  tendency  to  re- 
lapse which  may  still  linger  in  the  eyes,  and  which,  weie  this  pre- 
caution not  adopted,  might,  on  exposure  to  the  slightest  exciting 
cause,  lead  to  a  new  and  severe  attack. 

We  may  class  change  of  air  among  the  tonic  remedies  for  this  dis- 
ease, or  rather  among  the  preventives,  which  are  to  be  employed  after 
a  first  attack  is  subdued.  A  dry  warm  inland  situation  is  preferable 
to  the  sea-coast.  The  glare  from  the  sea  is  ver}'  apt  to  aggravate 
slight  attacks,  and  give  rise  to  relapses. 

5.  Alteratives.  Calomel  is  very  often  administered  in  strumous 
ophthalmia  ;  more  frequently,  however,  as  a  purgative  than  as  an  al- 
terative. That  this  medicine  is  injurious  to  children,  does  not  admit 
of  doubt.     That  their  constitutions  are  often  shattered  by  aa  indis- 


329 

criminate  use  of  calomel,  and  that  in  this  way  they  are  rendered 
more  susceptible  of  suffering  from  the  exciting  causes  of  scrofula, 
is  a  truth  which,  at  the  present  day,  is  overlooked  to  a  most  la- 
mentable degree. 

Given  as  an  alterative  in  strumous  ophthalmia,  I  have  fre- 
quently known  mercury  prove  injurious,  because  mistimed  ;  that 
is  to  say,  it  was  administered  before  the  irritation  attending  the 
acute  stage  of  the  disease  was  moderated  by  depletion.  After  local 
blood-letting,  and  the  use  of  evacuants,  we  sometimes  find  decided 
advantage  from  the  exhibition  of  calomel  with  opium.  This  com- 
bination may  even  be  pushed,  in  some  cases,  till  the  mouth  is  af' 
fected,  with  benefit. 

6.  Diaphoretics.  Keeping  up  a  healthy  action  of  the  skin  is 
of  much  importance  in  this  disease.  This  may  be  done  by  the 
tepid  bath  every  second  or  third  day,  followed  in  adults  by  the  use 
of  the  flesh-brush.  Dover's  powder  at  bedtime  sometimes  proves 
useful,  by  promoting  a  healthy  action  of  the  skin,  as  well  as  sooth- 
ing irritation,  and  procuring  sleep.  In  cases  where  the  perspiration 
is  immoderate,  this  medicine  is  not  less  remarkable  for  its  good  ef- 
fects than  where  the  surface  of  the  body  is  dry  and  husky.  Tar- 
tar emetic  operates  also  with  good  effect  on  the  skin,  and  sympa- 
thetically on  the  conjunctiva. 

7.  Diet.  During  the  continuance  of  an  attack  of  active  in- 
flammation, abstinence  from  animal  food,  and  from  all  kinds  of 
fermented  and  heating  liquors,  should  be  strictly  enjoined ;  but 
when  the  acute  symptoms  have  subsided,  and  the  disease  assumed 
a  chronic  character,  the  patient  ought  to  be  put  upon  rather  a 
generous  diet.  As  there  can  be  no  doubt  that  unwholesome  food 
is  one  of  the  chief  causes  of  scrofulous  ophthalmia  among  the 
poor,  it  is  of  much  importance  to  procure  for  the  patients  in  these 
circumstances,  a  more  invigorating  diet.  It  is  necessary  strictly  to 
forbid  the  use  of  articles  likely  to  derange  the  stomach ;  as,  pastry 
of  every  sort,  comfits,  vegeftible  jellies,  and  preserves  ;  and  indi- 
gestible substances,  as,  unripe  fruits,  nuts,  and  the  like. 

8.  Temper.  This  disease  is  extremely  apt  to  render  the  child 
fretful,  and  by  mismanagement  to  lay  the  foundation  of  bad  tem- 
per, which,  on  the  other  hand,  tends  much  to  prolong  and  aggra- 
vate the  symptoms.  We  find  in  good-natured  children,  and  in 
those  who  are  under  proper  management,  that  the  disease  disap- 
pears much  more  readily  ;  while  in  spoiled  children,  who  cry  per- 
haps for  hours  after  the  eyes  are  examined,  or  after  the  application 
of  any  remedy,  it  is  apt  to  become  almost  incurable. 

9.  Position  in  bed.  The  head  should  be  raised  as  much  as 
possible  during  the  night.  On  no  account,  ought  the  child  to  be 
suffered  to  he  burying  its  face  in  the  pillow. 

Local  remedies.     1.  Shading  the  eyes.     The  morbid  irritabil- 
ity which  marks  this  disease  so  strikingly  through  all  its  stages  is 
to  be  relieved  by  wearing  a  broad  green  shade  over  the  forehead ; 
42 


380 

and  by  avoiding  all  employment  of  the  eyes  upon  minute  objects^ 
especially  in  a  strong  light.  It  will  not  be  necessary  to  confine 
the  patient  to  a  daric  room,  nor  to  forbid  him  from  going  abroad  in 
fine  weather.  We  often  see  children  labouring  under  strumous 
ophthalmia  with  handkerchiefs  bound  over  their  eyes,  especially 
w'hen  they  are  taken  out  of  doors.  This  practice  is  decidedly  in- 
jurious, heating  the  eyes  too  much,  and  adding  to  the  intolerance 
of  light. 

2.  Evaporation.  In  recent  and  slight  attacks,  the  inflamma- 
tion, pain,  and  irritability,  may  be  moderated  by  the  use  of  evap- 
orating and  slightly  astringent  lotions,  applied  tepid  or  cold  accord- 
ing to  the  feelings  of  the  patient.  In  most  instances,  they  agree 
better  in  the  tepid  state.  A  decoction  of  poppy-heads,  with  a  few 
drops  of  alcohol ;  a  weak  solution  of  acetate  of  ammonia  ;  a  little 
rose  water  ;  or  a  solution  of  one  grain  of  corrosive  sublimate  in 
eight  ounces  of  water,  will  answer  the  purpose.  The  appUcation 
of  cold  water  to  the  eyelids,  face,  and  head,  generally  gives  relief 
in  this  ophthalmia ;  lout  in  many  cases,  the  reaction  which  follows 
is  hurtful.  The  same  may  be  said  of  alum  curd,  and  cold  sugar 
of  lead  poultices,  enclosed  in  a  thin  hnen  bag,  and  laid  over  the 
lids  at  bedtime. 

3.  Pomejitations.  When  the  symptoms  are  in  any  degree  se- 
vere or  of  long  continuance,  warm  soothing  applications  will  be 
found  more  useful  than  cold  ones.  With  a  bit  of  sponge  or  flan- 
nel, the  eyes  may  be  fomented  once  or  oftener  in  the  day  with 
hot  decoction  of  chamomile  flowers,  or  of  poppy-heads,  or  with  a 
hot  infusion  of  opium.  Much  relief  is  experienced  from  exposing 
the  eyes  to  the  vapour  of  laudanum,  or  of  camphor,  raised  by 
means  of  a  cupful  of  hot  water.  Warm  poultices  during  the  night 
are  often  useful.  They  are  to  be  made  with  crumb  of  bread, 
w^arm  water,  or  sugar  of  lead  water,  and  a  little  fresh  butter ;  and 
never  with  milk. 

4.  Scarification  of  the  inside  of  the  eyelids,  especially  in  chronic 
cases,  where  the  palpebral  conjunctiva  is  much  loaded  with  red 
vessels,  wall  be  found  one  of  the  most  valuable  means  of  cure.  In 
cases  of  vascular  speck,  division  of  the  fasciculus  of  vessels  running 
over  the  sclerotica  to  the  albugo,  cannot  be  dispensed  with ;  no 
other  remedy  having  the  same  power  in  checking  this^yery  annoy- 
ing and  dangerous  symptom. 

5.  Counter-irritation.  We  derive  great  benefit  from  blistering 
in  this  disease.  The  intolerance  of  hght  is  often  suddenly  and 
almost  completely  removed  by  this  remedy,  the  child  being  enabled^ 
in  a  few  hours  after  the  blister  rises,  to  open  its  eyes,  although  it 
had  not  done  so  for  months  before.  The  temples,  behind  the  ears, 
the  crown  and  back  of  the  head,  and  the  nape  of  the  neck,  are  the 
situations  generally  chosen  for  the  apphcation  of  bUsters.  The 
last  is  the  most  painful,  but  not  the  least  efiectual.  In  general,  the 
discharge  ought  to  be  kept  up,  by  the  use  of  some  stimulating: 


331 

dressing  ;  or  if  this  is  not  done,  a  quick  succession  of  blisters  ought 
to  be  employed. 

Friction  with  tartar  emetic  ointment  has  sometimes  been  had 
recourse  to  in  this  disease,  for  the  purpose  of  bringing  out  a  crop  of 
pustules.  This  is  a  practice  much  more  painful  than  blistering, 
the  pustules  if  considerable  in  size  leave  indelible  pits,  and  from 
mismanagement  of  the  remedy  large  portions  of  skin  are  some- 
times made  to  slough  ;  so  that,  on  the  whole,  blistering  is  prefer- 
able. 

Issues  in  the  neck  or  on  the  arm  are  beneficial,  both  in  relieving 
the  symptoms  of  strumous  ophthalmia,  and  in  preventing  relapses. 

6.  tSiimulants  applied  to  the  inflamed  surface  of  the  eye,  in  this 
disease,  are  decidedly  useful.  Indeed  it  is  scarcely  possible  to  effect 
a  cure  without  them.  The  impetiginous  state  of  the  conjunctiva, 
or  in  other  words  of  the  skin  covering  the  e)'^e,  which  constitutes 
strumous  ophthalmia,  not  merely  bears  stimulants,  but  like  most 
other  chronic  cutaneous  diseases,  is  uniformly  benefited  by  their 
application,  if  they  be  well  chosen,  carefully  used,  and  properly 
timed.  They  often  act  as  the  best  local  sedatives,  if  applied  after 
the  acute  inflammatory  excitement  is  subdued  by  the  general  reme- 
dies already  enumerated.  Employed  before  this  is  effected,  they 
will  scarcely  fail  to  prove  hurtful.  In  this  respect,  the  treatment 
of  scrofulous  ophthalmia  is  directly  contrary  to  that  of  the  puro- 
mucous  inflammations  of  the  conjunctiva  ;  for  in  them,  we  employ 
stimulants  from  the  very  first,  but  in  the  scrofulous  ophthalmia  we 
must  delay  till  the  symptoms  of  irritation  are  somewhat  abated. 

Various  stimulants  have  been  used  in  this  ophthalmia ;  but  the 
nitras  argenti  solution  and  the  red  precipitate  salve  are  the  most 
deserving  of  confidence.  Next  to  them,  I  would  place  the  vinum 
opii.  Whichever  be  selected,  its  application  must  be  continued 
with  regularity  once  a  day,  or  once  every  two  days,  the  child  being 
laid  in  the  horizontal  position,  the  head  fixed  between  the  knees, 
and  the  lid  opened  so  as  fully  to  expose  the  diseased  membrane. 
The  solution  of  four  grains  of  the  nitras  argenti  in  one  ounce  of 
distilled  water  is  the  stimulant  which  I  generally  employ.  It  evi- 
dently possesses  very  considerable  povv^er  in  abating  the  vascularity 
of  the  conjunctiva,  hastening  the  absorption  of  pustules,  cicatrizing 
ulcers,  and  clearing  specks  of  the  cornea.  The  relief  which  it 
affords  to  the  intolerance  of  light  is  not  the  least  of  its  good  effects. 
In  this,  it  probably  operates  by  inducing  the  healing  of  minute 
ulcerations,  and  the  contraction  of  enlarged  blood  vessels,  both  of 
which  give  rise  to  the  sensation  of  sand  in  the  eye,  to  spasm  of 
the  lids,  and  epiphora.  Whenever  ulceration  is  present  on  the 
cornea,  recourse  should  be  had  to  the  solution  of  nitras  argenti. 
A  stronger  solution  than  that  of  four  grains  to  the  ounce  of  distilled 
water  may  be  employed,  and  with  a  small  camel-hair  pencil  applied 
directly  to  the  surface  of  the  ulcer,  without  permitting  the  solution 
to  spread  over  the  rest  of  the  eyes. 


332 

7.  Solid  Caustic.  Where  an  ulcer  threatens  to  penetrate  deep 
into  the  substance  of  the  cornea,  or  when  it  has  already  perforated 
into  the  anterior  chamber,  with  or  without  prolapsus  of  the  iris,  it 
is  proper  to  touch  the  ulcer,  or  the  myo-cephalon,  every  second  or 
third  day,  with  a  pencil  of  lunar  caustic,  filed  to  a  sharp  point. 
Scarpa  has  given  the  best  account  of  the  effects  of  this  remedy,  to 
which  I  shall  again  have  occasion  to  refer,  under  the  head  of  ulcers 
of  the  cornea. 

8.  Belladonna.  The  case  of  James  Tassie,  already  detailed  at 
page  326,  strikingly  illustrates  the  utility  of  applying  the  extract 
of  belladonna  in  cases  of  central  ulcer  of  the  cornea.  Even  when 
the  edge  of  the  pupil  is  involved  in  such  an  ulcer,  the  dilating 
power  of  the  belladonna  may  be  sufficient  to  free  it,  and  thus  to 
preserve  the  pupil  entire.  In  cases  of  perforating  ulcer  near  the 
edge  of  the  cornea,  I  am  inchned  to  refrain  from  the  use  of  bella- 
donna ;  for,  while  the  dilatation  cannot  in  this  case  be  carried  so 
far  as  to  remove  the  iris  from  the  vicinity  of  the  ulcer,  I  believe 
the  state  of  palsy,  into  which  the  iris  is  thrown,  is  apt  to  favour 
rather  than  prevent  prolapsus. 

Relapses.  No  disease  is  so  apt  to  recur  as  scrofulous  ophthal- 
mia. It  is  therefore  necessary  for  children  who  have  once  suffered 
from  it  to  be  submitted,  from  time  to  time,  to  the  inspection  of 
their  medical  attendant,  who  must  endeavour  promptly  to  subdue 
every  symptom  of  a  re-attack,  and  to  conduct  his  patients  safely 
through  that  period  of  life  which  is  most  exposed  to  the  disease. 
In  this  way,  much  mischief  will  easily  be  prevented,  which, 
neglected,  may  require  years  to  remove,  or  prove  altogether  be- 
yond remedy. 


SECTION  X. ERYSIPELATOUS  OPHTHALMIA. 

Beer  has  described  an  erysipelatous  conjunctivitis.  It  appears 
to  be  a  rare  disease. 

Symptoms.  It  commences  with  a  slight  feeling  of  tension  in  the 
eye,  and  parts  immediately  surrounding  it.  The  conjunctiva  be- 
comes of  a  pale  red  colour  ;  and  rises  in  soft,  yellowish-red  vesicles 
round  the  cornea.  These  take  a  different  form  from  every  motion 
of  the  eyelids,  and  are  sometimes  so  large  as  to  project  from  be- 
tween their  edges.  On  strained  or  rapid  motion  of  the  eyeball,  or 
eyelids,  the  patient  feels  a  pricking  pain  in  the  eye.  When  the 
eyelids  are  a  little  open,  the  vesicles  give  the  patient  the  appearance 
of  one  who  is  weeping,  and  we  expect  that  at  every  moment  the 
tears  will  drop  from  his  eye ;  but  on  a  nearer  inspection,  and  on 
pulling  down  the  lower  eyelid,  we  discover  the  cause  of  the  mis- 
take, into  which  we  are  the  more  ready  to  fall,  as  during  this  in- 
flammation there  frequently  is  a  discharge  of  tears,  especially  on 
sudden  changes  of  temperature.     The  eye  is  somewhat  impatient 


333 

of  light.  No  other  diseased  appearances  are  observed  in  the  eye 
itself;  but  the  eyelids  seem  also  to  be  more  or  less  affected  with 
erysipelatous  inflammation.  At  the  end  of  the  acute  stage,  the 
pain  of  the  whole  eye  is  increased,  still  exciting  in  the  mind  of  the 
patient  the  comparison  of  pressing  or  stretching,  especially  on 
moving  the  eye  or  eyelids. 

As  the  disease  continues,  the  redness  of  the  conjunctiva  increases. 
It  becomes  indeed  so  generally  red,  that  we  discover  no  longer  a 
mere  net-work  of  blood-vessels,  but  a  general,  yet  pale,  and  some- 
times livid  redness.  Yet  this  pale  red  colour  is  not  uniform.  It  is 
contrasted  with  spots  of  different  sizes,  of  a  bright  red  colour,  which 
arise  from  extravasation  of  blood  into  the  cellular  substance  between 
the  conjunctiva  and  sclerotica.  The  vesicles  become  more  con- 
siderable, and  project  still  more  from  between  the  half-opened  eye- 
lids. The  spaces  between  the  vesicles  are  covered  with  a  thin  white 
mucus,  which  is  secreted  in  unnatural  quantity  by  the  conjunctiva 
and  Meibomian  glands.  The  discharge  of  tears  is  also  increased. 
During  the  night  the  eyelids  are  glued  slightly  together,  so  that  it  is 
with  some  difficulty  that  the  patient  opens  them  in  the  morning ; 
when  they  are  opened  the  cornea  appears  somewhat  dim ;  but  when 
the  eye  has  been  carefully  cleared,  we  see  that  the  apparent  dim- 
ness of  the  cornea  arises  entirely  from  the  mucus  collected  on  its 
surface. 

As  the  disease  begins  to  subside,  the  secretion  of  mucus  returns 
to  its  natural  quantity,  the  redness  of  the  conjunctiva  gradually 
disappears,  and  those  portions  of  that  membrane  which  had  been 
elevated  in  vesicles,  re-approach  and  re-attach  themselves  to  the 
tunica  albuginea  and  sclerotica.  The  discharge  of  tears  ceases  to 
be  so  frequent  and  so  abundant.  Those  spots  which  arose  from 
the  extravasation  of  blood  are  the  last  symptoms  to  disappear.  They 
become  of  a  yellowish-red  colour.  There  continues,  even  for  a  long 
time,  such  a  diminution  of  the  connexion  between  ihe  conjunctiva 
and  sclerotica  at  these  places,  that  the  conjunctiva  falls  into  wrinkles 
whenever  the  eyeball  is  moved.  It  is  long  before  it  recovers  com- 
pletely its  natural  pliancy  and  pellucid ness. 

Causes.  This  disease  arises  from  sudden  changes  of  atmos- 
phere, slight  blows,  the  stings  of  insects,  and  various  other  causes. 

Treatment.  Much  depletion  is  not  necessary.  The  exhibition 
of  a  purgative,  the  opening  of  the  vesicles  with  the  point  of  a  lancet, 
and  the  excitation  of  the  cutaneous  system  by  gentle  diaphoretics, 
will  in  most  cases  constitute  the  whole  of  the  necessary  means  of 
cure. 


SECTION  XI. VARIOLOUS  OPHTHALMIA. 

In  former  times  small-pox  proved  but  too  often  the  cause  of  seri- 
ous injury  to  the  eyes,  or  even  of  entire  loss  of  sight.     It  was  by  far 


334 

the  most  frequent  cause  of  partial  and  total  staphyloma.  But  since 
the  introduction  of  inoculation,  and  still  more  of  vaccination,  such 
injurious  effects  from  variolous  ophthalmia  are  much  more  rare. 

Syrnptojns.  In  most  cases  of  small-pox,  pustules  form  on  the 
external  surface,  and  on  the  margins  of  the  eyeUds.  When  they 
are  numerous,  as  in  confluent  small-pox,  they  cause  such  sweUing 
of  the  lids  as  completely  to  close  the  eyes.  As  the  disease  proceeds, 
matter  is  discharged  partly  from  the  Meibomian  follicles,  partly 
from  the  variolous  pustules,  the  eyelids  are  glued  together  so  that 
the  eyes  cannot  be  opened  for  days,  and  merely  from  this  state,  with- 
out any  pustules  being  formed  on  the  conjunctiva,  the  eyes  are 
irritated  and  painful.  At  last,  as  the  disease  subsides,  the  swelling 
of  the  lids  falls  so  that  they  are  again  opened,  and  the  eyes  may  be 
found  uninjured.  It  is  in  this  way  that  the  vulgar  talk  of  persons 
being  blind  in  small-pox  for  so  many  days,  and  then  perfectly  re- 
covering their  sight.  But  although  the  cornea  has  not  suffered  in 
these  cases,  the  eyelids  and  the  lachrymal  aparatus  are  often  left 
in  an  injured  state ;  and  not  unfrequently  small-pox  proves  the 
exciting  cause  of  strumous  affections  of  the  eyes  and  eyelids,  which 
may  continue  troublesome  for  years.  The  small  pox  pustules  on 
the  lids  are  apt  to  destroy  the  eyelashes,  to  leave  red  marks  and 
scars,  render  the  edges  irregular  and  liable  to  inflammation  and 
excoriation  from  slight  causes,  and  to  produce  ophthalmia  tarsi,  and 
very  frequently  trichiasis  and  distichiasis.  Chronic  blenorrhosa 
of  the  lachrymal  sac,  and  pustular  conjunctivitis,  are  also  frequent 
sequelse  of  small-pox. 

Schemes  have  been  proposed  for  preventing  the  pustules  of  small- 
pox from  spreading  to  the  face,  or  at  least  for  moderating  the  effects 
of  the  eruption.  We  find  that  this  disease  is  apt  to  attack  with 
peculiar  severity  any  part  of  the  surface  of  the  body  labouring  at  the 
time  under  accidental  irritation,  and  hence  it  has  been  supposed 
that  soothing  applications  may  moderate  the  eruption  and  its  effects. 
Covering  the  face  with  a  cloth  spread  with  cerate,  and  fomenting 
it  from  time  to  time  with  chamomile  decoction,  have  been  used  for 
this  purpose,  and  can  do  no  harm.  When  the  pustules  on  the  eye- 
lids are  fully  matured,  we  may  afford  considerable  relief  b)"  pricking 
them  one  by  one  with  a  needle,  so  as  to  evacuate  their  contents  ; 
and  by  carefully  removing  the  crusts  which  form  after  the  pustules 
burst,  having  first  softened  them  with  some  mild  ointment.  The 
lids  are  frequently  to  be  bathed  with  tepid  milk  and  water,  and  bits 
of  soft  rag  moistened  with  the  same  are  to  be  laid  over  them. 

There  is  in  every  case  of  small-pox,  some  redness  of  the  conjunc- 
tiva. But  danger  is  chiefly  to  be  apprehended  when  a  variolous 
pustule  or  pustules  appear  on  the  cornea,  where,  unfortunately,  they 
are  much  more  apt  to  occur  than  on  the  conjunctiva  covering  the 
sclerotica.  A  pustule  on  the  cornea,  forming  at  the  time  of  the 
general  eruption,  is  extremely  apt  to  prove  destructive.  When  it 
bursts,  the  ulcer  thus  formed  but  too  often  deepens  and  spreads,  the 


335 

cornea  is  penetrated,  the  iris  advances  and  adheres ;  the  pupil  may 
thus  be  obhterated,  or  the  cornea  being  much  changed  in  structure, 
and  adherent,  in  a  great  part  of  its  extent,  or  completely,  to  the  iris, 
partial  or  total  staphyloma  may  be  the  result.  In  bad  cases,  almost 
the  whole  of  the  cornea  is  destroyed,  by  infiltration  of  matter  and 
ulceration. 

During  the  suppurative  stage  of  small-pox  it  is  difficult  to  say 
vi^hat  extent  of  mischief  is  going  on  in  the  eye,  under  the  closed  and 
swoln  eyehds.  If  the  patient  feels  pain  in  the  ball  itself,  with  dry- 
ness, stifTness,  and  a  sensation  of  sand  in  the  eye  ;  if  the  uneasiness 
be  much  increased  on  attempting  to  move  the  eye,  or  on  exposing 
it  to  light  even  through  the  swoln  lids;  and  if,  in  addition  to  the 
matter  discharged  from  the  pustules  on  the  edges  of  the  lids  and 
from  the  Meibomian  foUicles,  there  is  a  frequent  discharge  of  hot 
tears,  then  it  is  probable  that  there  is  acute  variolous  conjunctivitis, 
and  perhaps  pustules  on  the  cornea.  But  if  the  eye  is  easy,  only 
shut  up  from  the  state  of  the  lids,  there  is  probably  no  danger. 

The  eyes,  however,  are  not  safe,  even  after  the  small-pox  pustules 
over  the  body  have  blackened  and  the  scabs  fallen  off,  I  have  seen 
both  pustule  of  the  cornea  and  onyx  produced  after  the  general 
eruption  was  completely  gone.  This  has  been  called  with  suffi- 
cient propriety,  secondary  variolous  ophthahnia.  It  sometimes 
occurs  as  late  as  five  or  six  weeks  after  the  patient  has  recovered 
from  the  primary  disease.  It  is  certainly  not  so  severe  an  affection 
as  the  primary,  but  is  still  dangerous  in  regard  to  vision.  A  dull 
whitish  point  is  observed  in  the  cornea,  with  surrounding  haziness ; 
the  whiteness  becomes  more  extensive,  amounting  perhaps  to  the 
12th  of  an  inch  in  diameter,  and  then  the  part  becomes  yellow.  If 
two  or  more  such  points  should  form,  the  whole  cornea  is  rendered 
nebulous  ;  or  this  effect  may  be  produced  even  from  one  large  vari- 
olous pustule.  An  onyx  at  the  same  time  may  appear  at  the  low- 
er edge  of  the  cornea.  The  sclerotica  is  reddened.  Pain  and  epi- 
phora are  excited  on  exposure  to  light. 

The  secondary  variolous  ophthalmia  seldom  leads  to  destruction 
of  the  cornea.  By  proper  treatment,  the  matter  of  the  pustules  or 
onyx  is  sometimes  absorbed.  In  other  cases,  ulceration  takes  place, 
leaving,  after  cicatrization,  a  permanent  leucoma  or  white  speck- 
The  surrounding  haziness  of  the  cornea  is  gradually  dissipated  ; 
vision  is  injured  according  to  the  situation  and  size  of  the  leucoma. 
By  the  formation  of  an  artificial  pupil,  vision  may  in  many  cases 
of  this  sort  be  restored.  Even  when  partial  staphyloma  has  formed, 
this  operation  is  often  applicable. 

Treatment.  The  best  general  treatment  of  small-pox  must  be 
followed  ;  a  moderate  temperature,  tepid  ablution,  and  a  cool  regi- 
men. Emetics  are  occasionally  useful ;  even  blood-letting  may  be 
cautiously  employed  in  some  cases,  and  laxatives  are  always  to  be 
administered.  If  the  eyes  are  particularly  affected,  they  must  be 
frequently  bathed  with  tepid  water  or  poppy  decoction,  and  the  edges 


336 

of  the  lids  smeared  with  a  Uttle  cold  cream.  In  many  cases,  the 
Hds  are  so  much  swoln,  and  so  completely  sealed  up,  that  it  would 
be  in  vain  to  attempt  any  application  to  the  conjunctiva,  till  the 
eruption  begins  to  fade  and  the  swelling  to  fall.  Leeches  may  be 
applied,  not  only  without  impropriety,  but  with  decided  advantage, 
behind  the  ears  or  on  the  temples,  and  followed,  if  it  appear  neces- 
sary, by  bUsters.  About  the  eighth  or  ninth  day  of  the  eruption, 
free  purging  will  be  found  useful,  not  merely  in  reducing  the  suppu- 
rative fever,  but  in  relieving  the  uneasy  and  inflamed  state  of  the 
eyes.  The  lids  now  begin  to  be  opened,  so  that  a  little  fluid  can 
be  injected  between  them  and  the  eyeball.  A  weak  solution  of  ul- 
tras argenti,  or  diluted  vinum  opii,  may  be  used  for  this  purpose. 

As  to  the  treatment  of  secondary  variolous  ophthalmia,  I  have 
found  tartar  emetiC;  given  so  as  to  vomit  and  purge  freely,  to  be 
productive  of  the  best  effects,  evidently  abating  the  inflammation, 
and  promoting  the  absorption  of  the  pustules  and  onyx.  Leeches 
and  blisters  are  also  useful.  As  soon  as  the  acuteness  of  the  in- 
flammation is  somewhat  abated  by  these  means,  much  advantage 
will  be  gained  by  putting  the  patient  on  a  course  of  sulphate  of 
quina.  Undiluted  vinum  opii  appears  to  answer  best  as  a  local  ap- 
plication. The  eye  is  to  be  touched  with  it  once  a  day.  Belladon- 
na is  to  be  applied  to  the  eyebrow,  in  order  to  keep  the  pupil  di- 
lated. 


SECTION  XII. MORBILLOUS  AND    SCARLATINOUS    OPHTHALMIA. 

A  certain  degree  of  conjunctivitis  always  attends  measles  and 
scarlet  fever,  but  is  in  general  much  less  severe  than  the  variolous 
inflammation  of  the  eye.  In  measles  and  scarlet  fever,  the  change 
which  the  skin  undergoes,  amounts  to  little  more  than  vascular 
congestion,  and  the  conjunctiva,  a  prolongation  of  skin,  betrays 
therefore  little  more  during  the  presence  of  these  diseases,  than 
some  degree  of  redness,  with  intolerance  of  light,  shght  pain,  and 
epiphora.  Occasionally,  however,  we  have  phlyctenulee,  onyx,  and 
ulcers  of  the  cornea,  brought  on  by  the  morbillous  and  scarlatinous 
ophthalmiae,  particularly  when  the  subject  is  scrofulous.  Indeed, 
it  is  difficult  to  distinguish  either  of  these  ophthalmiae  from  the 
scrofulous,  till  the  eruption  on  the  skin  makes  its  appearance.  On 
the  other  hand,  we  often  hear  of  the  dregs  of  the  measles  and  of 
scarlet  fever  producing  affections  of  the  eye  and  eyelids.  By  this, 
is  generally  meant  that  the  scrofulous  diathesis  has  been  called 
into  action  by  these  diseases,  and  that  ophthalmia  tarsi  or  phlyc- 
tenular conjunctivitis  has  been  the  result. 

In  measles  there  is  a  catarrhal  affection  of  the  Schneiderian 
membrane,  wdth  sneezing  and  cough,  and  occasionally  the  attend- 
ing conjunctivitis  is  not  so  much  eruptive  as  blenorrhoeal.  I  have 
seen  cases  in  which  the  eye  had  been  destroyed  by  severe  puro- 
mucous  ophthalmia  excited  by  measles. 


337 

In  some  rare  cases  of  scarlatinous  ophthalmia,  the  iris  and  cap- 
sule of  the  lens  become  affected.  I  operated  some  time  ago  on  a 
boy  of  about  eight  years  of  age,  in  whom  specks  of  the  anterior 
hemisphere  of  the  capsule  were  brought  on  in  this  way. 

Treatment.  The  affection  of  the  eye  in  measles  and  scarlet 
fever,  does  not  in  general  require  active  treatment.  The  eyes 
should  be  guarded  from  strong  light,  bathed  occasionally  with  tepid 
water,  and  the  bowels  kept  freely  open.  If  the  symptoms  are  more 
than  commonly  severe,  leeches  may  be  set  on  the  temples,  and 
blisters  applied  behind  the  ears,  or  to  the  nape  of  the  neck.  The 
nitras  argenti  solution  will  be  found  highly  useful,  whether  the 
ophthalmia  be  eruptive  or  puro-mucous.  Sulphate  of  quina  may 
be  given  internally  with  good  effects. 


SECTION    XIII. RHEUMATIC  OPHTHALMIA. 

It  has  already  been  stated,  that  the  three  inflammator}'^  diseases 
of  the  eye,  most  frequently  arising  in  adults  from  atmospheric  in- 
fluences, are  the  catarrhal,  the  rheumatic,  and  the  catarrho-rheu- 
matic. 

Diagnosis.  The  following  particulars  will  serve  sufficiently 
to  distinguish  the  rheumatic  from  the  catarrhal  ophthalmia. 

1.  Seat  of  the  disease.  The  catarrhal  ophthalmia  is  an  affec- 
tion of  the  conjunctiva  ;  the  rheumatic  has  its  seat  in  the  albugi- 
nea  and  sclerotica,  and  extends  occasionally  to  the  iris. 

2.  Redness.  The  redness  in  the  catarrhal  is  reticular,  and  the 
turgid  vessels  are  evidently  conjunctival;  in  the  rheumatic,  the 
chief  redness  is  radiated  or  zonular,  and  seated  under  the  con- 
junctiva. 

3.  Nature  of  the  inflammation.  The  catarrhal  ophthalmia  is 
an  inflammation  of  a  mucous  membrane,  and  is  a  blenorrhoeal  or 
profluvial  disease,  attended  with  an  increased  and  morbid  secretion 
of  mucus ;  the  rheumatic,  attacks  the  fibrous  membranes  of  the 
organ  of  vision,  and  is  unattended  by  any  morbid  secretion  from 
the  surface  of  the  eye. 

4.  Pain.  The  pain  in  the  catarrhal  ophthalmia  arises  on  the 
surface  of  the  conjunctiva,  is  compared  to  the  sensation  of  rough- 
ness, or  to  the  feeling  which  might  be  excited  by  sand  or  broken 
glass  under  the  eyelids,  does  not  extend  to  the  head,  and  is  felt 
most  in  the  morning,  or  when  the  eyes  begin  to  be  moved :  the 
pain  of  the  eyes  in  the  rheumatic  ophthalmia  is  pulsative  and 
deep-seated,  the  chief  pain,  however,  is  not  in  the  eye,  but  round 
the  orbit,  in  the  eyebrow,  temple,  cheek,  and  side  of  the  nose,  and 
is  severely  aggravated  from  sunset  till  sunrise. 

If  it  be  asked,  "  What  is  meant  by  rheumatic  ophthalmia  ?  "  I 
should  reply  that — 

^  Sclerotitis  Rheumatica  vel  Atmospherica. 

43 


338 

1.  I  mean  simple  inflammation  of  the  fibrous  tissue  of  the  eye^ 
(the  sclerotica),  and  of  the  surrounding  parts  of  similar  structure, 
excited  by  exposure  to  cold. 

2.  I  do  not  believe  it  to  be  an  inflammation  differing  from  com- 
mon inflammation  m  kind,  in  consequence  of  the  existence  of  what 
has  been  called  the  rheumatic  habit,  or  diathesis.  When  atmos- 
pheric influence  produces  catarrh,  we  never  hear  the  occurrence 
referred  to  a  mucous  diathesis :  nor,  when  pleuritis  arises  from  the 
same  cause,  do  we  attribute  the  disease  to  a  serous  diathesis.  The 
same  exciting  cause,  affecting  a  fibrous  instead  of  a  mucous  or  a 
serous  membrane,  produces  a  new  train  of  symptoms,  dependent 
not  on  the  constitution  of  the  person,  but  on  the  structure  and 
functions  of  the  part  affected. 

3.  Rheumatic  ophthalmia  frequently  occurs  in  individuals  who 
have  never  suffered  from  rheumatism  in  any  other  part  of  the 
body. 

4.  When  rheumatism  quits  a  joint  and  attacks  the  heart,  which 
I  have  known  prove  fatal  we  say  it  is  a  metastasis  from  the  former 
to  the  latter  situation  ;  but  such  a  translation  of  rheumatic  inflam- 
mation I  have  never  myself  observed  in  regard  to  the  eye.  In  all 
the  cases  of  rheumatic  sclerotitis  which  I  have  witnessed,  the  disease 
was  primary,  whether  in  rheumatic  or  non-rheumatic  subjects, 
never  metastatic. 

5.  I  have  adopted  the  cerm  rheumatic  oj^hthalmia  ;  but,  per- 
haps, sclerotitis  atmospherica  would  be  a  truer  appellation.  It 
must  be  confessed;  however,  that  this  inflammation  of  the  eye  re- 
sembles rheumatism  in  its  exciting  causes^  its  accompanying  pain, 
its  exacerbations,  and  its  cure.  It  has  nx3t  been  generally  recog- 
nised as  rheumatic,  probably  because  it  attacks  a  structure  which 
is  covered  only  by  a  thin  semi-transparent  membrane,  and  therefore 
exposed  to  direct  examination  ;  while  the  other  seats  of  rheumatism, 
unlike  this,  are  hid  from  our  view  by  the  whole  thickness  of  the 
common  integuments,  and  are  the  subjects,  therefore;  more  of  con- 
jecture than  of  actual  observation. 

Degree  of  frequency .  The  pure  rheumatic  ophthalmia  is  com- 
paratively a  rare  disease.  For  one  case  of  pure  rheumatic,  we  meet 
wnth  perhaps  ten  cases  of  catarrhal  ophthalmia,  and  six  of  that  mixed 
kind  called  catarrho-rheumatic,  in  W'hich  both  conjunctiva  and  scle- 
rotica are  affected,  and  the  symptoms  of  the  two  former  ophthalmias 
combined.  We  seldom  see  both  eyes  affected  with  rheumatic  oph- 
thalmia at  once.  When  both  are  attacked,  the  one  is  always  much 
more  severely  inflamed  than  the  other. 

Local  symptoms.  1.  The  fasciculi  of  sclerotic  vessels  advance 
in  radii  towards  the  edge,  and  sometimes  even  a  little  over  the  edge 
of  the  cornea.  They  are  of  a  bright  red  colour,  and  surround  the 
cornea  pretty  equally  on  all  sides.  They  are  larger  and  more  tur- 
gid than  the  radiating  vessels  seen  in  iritis,  and  rise  more  from  the 
surface  of  the  slerotica.     The  conjunctivitis  which  attends  this 


339 

ophthalmia  is  slight,  and  never  such  as  to  mask  the  radiated  in- 
flammation of  the  sclerotica. 

2.  There  is,  in  general,  no  tendency  to  chemosis  in  the  pure 
rheumatic  ophthalmia,  nor  do  the  eyelids  take  part  in  the  dis- 
ease. 

3.  Dimness  of  vision  uniformly  attends  this  ophthalmia,  depend- 
ing on  an  accompanying  haziness  of  the  cornea  and  pupil,  attended 
by  a  slight  contraction  of  the  latter,  and  sluggishness  in  the  move- 
ments of  the  iris,  df  only  one  eye  is  affected,  which,  at  least  for 
some  time,  is  generally  the  case,  the  pupil  of  that  eye  is  seen  at 
once  to  be  less  than  that  of  the  sound  eye.  The  iris  becomes  even 
slightly  discoloured  ;  it  becomes  greenish,  for  instance,  if  naturally 
blue  ;  and  the  attending  iritis  may  go  on  to  evident  effusion  of  co- 
agulable  lymph  within  the  pupil.  It  must  be  understood,  howev- 
er, that  a  severe  degree  of  iritis  rarely  attends  this  rheumatic  scle- 
rotitis. 

5.  Except  haziness  of  the  cornea  and  pupil,  which  may  be  attri- 
buted to  slight  effusion,  it  has  never  happened  to  me  to  witness  any 
other  of  the  secondary  phenomena  of  inflammation  in  pure  rheu- 
matic ophthalmia.  I  have  not  seen  the  disease  terminate  in  any 
form  of  suppuration  or  of  ulceration,  both  of  which  are  very  common 
in  the  catarrho-rheumatic  ophthalmia. 

5.  The  access  of  light  does  not  in  general  prove  very  distressing 
to  the  patient  in  rheumatic  ophthalmia.  The  affected  eye  feels  dry 
and  hot  in  the  early  period  of  the  disease ;  but  after  a  time,  espe- 
cially when  the  symptoms  are  somewhat  abated  by  blood-letting, 
there  is  considerable  epiphora. 

6.  The  pain  which  attends  the  rheumatic  ophthalmia  at  its 
commencement  is  of  a  stinging  kind,  and  extends  from  the  eyeball 
to  the  orbit,  and  neighbouring  parts  of  the  head.  These  parts  feel 
hot  to  the  patient,  and  even  to  the  hand  of  the  observer.  The 
pain  is  strikingly  augmented  by  warmth.  It  often  affects  the 
forehead,  the  cheek-bone,  and  the  teeth  ;  extending  sometimes  even 
to  the  lower  jaw.  Occasionally,  it  is  precisely  confined  to  one  half 
of  the  head.  In  some  instances,  it  is  severe  on  the  side,  or  even  in 
the  cavity  of  the  nose,  or  in  the  ear.  But,  above  all,  the  eyebrow 
is  its  chief  seat,  and  next  to  it  the  temple  and  the  cheek.  It  is  not 
unfrequently  the  acute  pulsatory  pain  of  phlegmon,  especially  when 
felt  chiefly  in  the  eyeball ;  in  other  cases,  and  particularly  around 
the  orbit,  it  consists  rather  in  an  agonizing  kind  of  feehng,  which 
distresses  and  wearies  out  the  patience  of  the  person  affected.  It 
never  ceases  entirely,  so  long  as  the  disease  continues ;  but  it  varies 
much  in  degree,  coming  on  with  severity  about  four,  six,  or  eight 
o'clock  in  the  evening,  continuing  during  night,  becoming  most 
severe  about  midnight,  and  abating  towards  five  or  six  in  the 
morning ;  till  then  totally  preventing  sleep,  and  occasioning  great 
distress. 

The  patient  never  fails,  in  the  history  he  gives  of  his  case,  to  in- 


340 

sist  on  the  nocturnal  pain,  and  with  his  finger  to  point  out  its  cir- 
cum-orbital  seat.  It  is  much  more  in  the  forehead,  temple,  cheek, 
and  side  of  the  nose,  than  in  the  eye.  It  is  reasonable  to  conclude 
that  in  this  disease  the  periosteum  in  and  round  the  orbit,  and  the 
fascia  of  the  temporal  muscle,  (structures  similar  to  the  sclerotica), 
are  also  affected  with  rheumatism  ;  but  the  chief  seats  of  the  pain 
are,  in  all  probabiht}-,  the  branches  of  the  fifth  pair  of  nerves  dis-- 
tributed  to  the  face,  and  we  may  fairly  attribute  a  considerable  por- 
tion of  the  pain  to  the  sympathy  w^hich  these  nerves  have  with 
those  belonging  to  the  eyeball. 

Constitutional  Symptoms.  A  considerable  degree  of  symp- 
tomatic fever  attends  this  disease,  increasing  along  with  the  noctur- 
nal paroxysms  of  pain.  The  pulse  becomes  frequent,  and  some- 
times strong,  full,  and  hard.  The  tongue  is  white  and  furred,  and 
the  mouth  ill-tasted  ;  there  is  more  or  less  nausea,  and  the  skin  is 
hot  and  dry.  The  digestive  organs  are  deranged,  the  appetite  im- 
paired, the  bowels  generally  confined,  and  the  excretions  morbid. 

The  progress  and  severity  of  the  disease  vary  much  in  different 
cases.  In  some  the  attack  is  slight,  and  soon  goes  off,  without  per- 
manently injuring  the  organ.  At  other  times,  it  is  extremely  se- 
vere, and,  if  misunderstood,  may  soon  destroy  vision.  Not  uufre- 
quently  the  disease  falls  into  a  chronic  state,  without  being  very 
severe. 

Excitijig  Causes.  Rheumatic  ophthalmia  may  be  distinctly 
traced,  in  most  instances,  to  exposure  of  the  eye  to  a  continued  blast 
of  cold  air,  while  the  head  and  face  are  in  a  state  of  perspiration. 
The  patient,  in  the  history  w^hich  he  gives  of  his  case,  commonly 
mentions  some  particular  exposure  of  this  sort,  soon  after  which  the 
redness  and  rheumatic  pain  commenced  ;  for  example,  sleeping 
"with  the  head  exposed  to  the  air  entering  by  a  chink  in  the  wall, 
or  by  a  broken  pane  of  glass  ;  travelHng  during  the  night,  with 
one  side  of  the  head  close  to  the  broken  window  of  a  carriage  ; 
suddenly  issuing  from  a  crowded  room  into  the  cold  air  of  the  street ; 
exposure  to  the  blast  which  flows  from  the  stage  into  the  body  of  a 
theatre  ;  keeping  wet  clothes  on  the  head  when  overheated  ;  and 
the  like. 

I  have  not  observed  that  this  disease  is  much  more  apt  to  occur 
at  one  season  of  the  year  than  another.  It  is  certainly  more  prev- 
alent when  the  wind  is  cold  and  north-easterly.  It  is  much  more 
apt  to  attack  persons  of  middle-age  than  either  the  young  or  the 
old.  Indeed,  I  have  never  seen  it  in  children,  nor  in  those  fai  ad- 
vanced in  life.  Probably  the  same  exciting  causes  which,  in  per- 
sons of  middle-life  and  robust  constitution,  are  apt  to  induce  rheu- 
matic ophthalmia,  would  in  a  child  excite  catarrhal  or  scrofulous 
ophthalmia,  and  in  an  old  person  the  catarrho-rheumatic.  Rheu- 
matic ophthalmia  is  very  apt  to  re-attack  an  individual  who  has 
previously  suffered  from  it. 

Treatment.     1.  Blood-letting.     In  plethoric  persons,  with  a 


341 

full  and  hard  pulse,  and  indeed  in  almost  all  cases  of  rheumatic 
ophthalmia,  it  is  necessary  to  take  away  blood  from  the  arm,  and 
to  apply  leeches  to  the  forehead  and  temple.  1  feel  myself  obliged 
to  d\fff.r  entirely  from  Mr.  Wardrop  in  his  opinion  that  patients  af- 
fected with  rheumatic  ophthalmia  neither  bear  bleeding  to  a  great 
extent,  nor  are  much  relieved  by  this  remedy.  He  has  even  stated 
the  hltle  relief  afforded  by  bleeding  in  this  disease  as  one  of  its  diag- 
nostic characters.*  This  entirely  disagrees  with  my  experience  ; 
and  is,  I  apprehend,  altogether  contrary  to  what  we  observe  in 
other  rheumatic  affections.  Bleeding,  both  general  and  local,  I 
have  uniformly  found  extremely  useful  in  rheumatic  ophthalmia, 
and  I  believe  it  ought  seldom  if  ever  to  be  omitted.  The  first  night 
after  taking  fifteen  or  twenty  ounces  of  blood  from  the  arm,  the 
patient  is  generally  so  much  relieved  as  to  get  some  sleep,  even 
though  no  other  remedy  be  employed.  Next  day,  I  am  in  the 
habit  of  applying  a  dozen  of  leeches  round  the  eye  ;  but,[if  the  pulse 
be  still  strong  and  full,  and  the  circum-orbital  pain  not  relieved,  I 
first  repeat  the  venesection. 

2.  Calomel  and  opium.  I  have  never  failed  to  find  this  com- 
bination highly  useful  in  checking  the  circum-orbital  pain,  and  dis- 
sipating the  other  symptoms  of  this  ophthalmia.  Two  grains  of 
calomel,  with  one  of  opium,  are  to  be  continued  every  evening  till 
the  gums  begin  to  be  affected,  when  the  calomel  may  be  omitted, 
and  ten  grains  of  Dover's  powder  substituted  for  the  opium.  Mr. 
Wardrop  states  that  mercury,  given  in  this  disease  so  as  to  produce 
ptyalism,  aggravates  more  than  mitigates  the  symptoms.  This 
does  not  correspond  with  what  I  have  observed.  1  do  not,  indeed, 
push  the  murcury  in  order  to  affect  the  mouth,  but  I  have  not  wit- 
nessed any  bad  effects  from  the  mouth  becoming  sore. 

3.  Opiate  Frictions.  The  patient  experiences  great  relief 
from  carefully  rubbing  the  forehead  and  temple  with  warm  lauda- 
num. Beer  used  opium  moistened  with  saliva.  Friction  with 
either  of  these  assuages  the  pain,  if  already  present ;  but  ought  to 
be  employed  rather  about  an  hour  before  the  nocturnal  paroxysm 
is  expected,  which  it  will  greatly  lessen,  and  sometimes  entirely 
prevent.  In  chronic  cases,  equal  parts  of  laudanum,  and  tincture  of 
cantharides,  may  be  used  for  this  purpose. 

4.  Blisters^  repeatedly  applied  behind  the  ear,  and  to  the  temple, 
but  above  all  a  large  blister  to  the  nape  of  the  neck,  will  be  found 
useful. 

5.  Belladnnna.  During  the  whole  course  of  rheumatic  ophthal- 
mia, the  pupil  of  the  affected  eye  ought  to  be  kept  under  the  influ- 
ence of  belladonna,  either  by  smearing  the  moistened  extract  upon 
the  eyebrow  and  eyelids  every  evening,  at  bedtime,  or  by  infusing 
one  drachm  of  the  extract  in  each  ounce  of  the  laudanum  which  is 
used  for  rubbing  the  head. 

•  Medico  Chirurgical  Transactions.    Vol.  x.  p.  13.    London,  1819. 


342 

6.  Purgatives.  A  laxative  clyster  every  morning,  or  a  small 
dose  of  Epsom  salts,  may  be  given  to  obviate  the  constipating  effects 
of  the  opium.  More  powerful  purgatives  are  improper,  as  they 
would  carry  off  the  calomel  and  opium,  and  thereby  prevent  their 
good  effects, 

7.  Sudorijics.  The  warm  pediluvium  at  bedtime,  with  warm 
diluent  drinks  towards  evening,  operating  along  with  the  opium, 
will,  in  general,  excite  a  sufficient  degree  of  diaphoresis.  Mr. 
Wardrop  recommends  antimonial  powder,  and  Beer  employed  gua- 
iac  for  exciting  the  skin  in  this  disease. 

8.  Tonics.  Small  doses  of  sulphate  of  quina,  or  of  the  mineral 
acids,  will  be  found  advantageous  in  the  chronic  stage  of  the  dis- 
ease, and  during  convalescence.  In  old  mistreated  cases,  Fowler's 
solution  sometimes  gives  great  relief,  in  doses  of  from  eight  to  twelve 
drops  thrice  a  day. 

9.  Vinum  opii.  Applications  to  the  eye  itself  have  but  little 
power  over  this  disease.  Those  which  are  so  useful  in  other  oph- 
thalmiee,  are  often  hurtful  in  the  rheumatic.  The  lunar  caustic 
solution,  for  instance,  which  may  be  regarded  as  a  specific  in  catar- 
rhal ophthalmia,  is  in  the  present  disease  decidedly  injurious.  When 
all  the  febrile  and  painful  symptoms,  however,  are  gone,  and  little 
more  than  lingering  redness,  with  weakness  of  the  eye,  remains, 
the  vinum  opii,  in  a  diluted  state,  will  be  found  beneficial,  dropped 
upon  the  eye  twice  or  thrice,  or  the  pure  vinum  opii,  once,  daily. 

The  first,  second,  third,  and  fifth  of  these  remedies  are  to  be  had 
recourse  to  in  the  first  instance.  I  have  never  seen  these  remedies 
fail  in  any  acute  case,  however  severe  ;  nor  have  I  seen  ari}^  per- 
manent sequelae,  when  the  plan  of  treatment  now  explained  was 
adopted  with  the  necessary  vigour. 


SECTION  XIV. CA.TARRHO-RHEUMATIC  OPHTHALMIA. 

This  compound  ophthalmia  is  one  of  the  most  common,  and  also 
one  of  the  most  severe  and  dangerous.  In  old  persons  especially, 
it  is  often  the  source  of  permanently  diminished  vision,  and  not  un- 
frequently  of  entire  loss  of  sight  in  the  eye  attacked. 

^ymptoins.  1.  As  both  the  conjunctiva  and  the  sclerotica  are 
affected,  the  symptoms  are  more  coraphcated,  and  also  more  vari- 
ous, than  those  of  unmixed  conjunctivitis  or  sclerotitis. 

2.  The  feehng  of  roughness  or  of  sand  between  the  eyelids  and 
eyeball,  the  secretion  of  puriform  mucus,  and  puriform  Meibomian 
fluid,  are  sufficiently  indicative  of  the  part  taken  in  this  disease  by 
the  conjunctiva.  The  nocturnal  accession  of  racking  circum-orbital 
pain  marks  the  affection  of  the  sclerotica. 

In  some  cases  of  catarrho-rheumatic  ophthalmia,  the  conjuncti- 
vitis is  severe,  the  sclerotitis  slight :  but  more  frequently  the  sclero- 
titis is  severe,  and  the  conjunctivitis  not  so  considerable. 


343 

4.  In  this  disease,  the  conjunctiva  and  sclerotica  are  attacked 
simultaneously.  Occasionally  it  happens  in  the  course  of  pure 
rheumatic  ophthalmia,  that  the  patient,  from  some  new  exposure, 
becomes  affected  also  with  catarrhal  conjunctivitis  ;  more  rarely 
does  an  attack  of  rheumatic  sclerotitis  supervene  in  catarrhal  oph- 
thalmia. But  in  catarrho-rheumatic  ophthalmia,  both  membranes 
appear  to  be  attacked  at  once,  in  consequence  of  the  influence  of  one 
and  the  same  exciting  cause. 

5.  In  this  disease,  the  redness  is  evidently  both  conjunctival  and 
sclerotic.  Under  the  movable  network  of  the  conjunctiva,  we  per- 
ceive the  immovable  zonular  inflammation  of  the  sclerotica.  In 
pure  catarrhal  ophthalmia,  the  sclerotica,  no  doubt,  partakes  in  the 
inflammation  of  the  investing  tunic,  but  no  paroxysms  of  rheumatic 
pain  are  present ;  the  sclerotica  suffers  sympathetically,  not  prima- 
rily. In  pure  rheumatic  ophthalmia,  also,  the  conjunctiva  is  red- 
dened, from  contiguous  sympathy  with  the  structure  which  it  covers, 
just  as  the  skin  is  reddened  over  a  joint  suffering  from  acute  rheu- 
matism ;  but  neither  the  conjunctiva  in  the  one  instance,  nor  the 
skin  in  the  other,  is  the  seat  of  the  primary  disease.  Besides,  in 
pure  rheumatic  ophthalmia,  the  conjunctiva  betrays  no  marks  of 
profluvial  disease. 

6.  Cheraosis,  or  inflammatory  oedema  of  the  sub-conjunctival 
cellular  membrane,  is  by  no  means  an  uncommon  attendant  on 
catarrho-rheumatic  ophthalmia.  When  it  does  occur,  it  hides  from 
view  the  sclewtic  redness. 

7.  The  discharge  from  the  conjunctiva  in  this  disease  is  never 
profuse,  and  seldom  opaque.  It  amounts,  in  general,  rather  to  a 
mere  increase  of  mucus,  than  a  flow  of  pus,  and  renders  the  lids 
more  than  usually  moist  and  slippery. 

8.  The  eyelids  adhere  together  in  the  morning,  from  the  inspis- 
sated Meibomian  secretion.  Not  unfrequently  they  are  also  exter- 
nally red  and  swollen. 

9.  Considerable  intolerance  of  light  and  epiphora  attend  this 
ophthalmia  in  all  its  stages  ;  but  especially  in  those  cases  where  the 
structure  of  the  cornea  is  affected. 

10.  The  conjunctival  pain,  which  is  compared  to  the  feeling 
produced  by  sand  between  the  eyelids  and  eyeball,  is  felt  most  in 
the  morning,  or  when  the  eyelids  are  moved.  The  sclerotic  pain 
is  nocturnal,  and  observes  the  same  periods  of  renewal,  violence, 
and  abatement,  which  are  observed  in  rheumatic  ophthalmia.  The 
conjunctival  pain  is  referred  to  the  surface  of  the  eye,  and  sometimes 
to  the  forehead.     The  sclerotic  pain  is  circum-orbital. 

11.  In  this  disease,  the  cornea  is  extremely  apt  to  suffer  from 
ulceration,  and  from  effusion  of  pus  between  its  lamellae.  Indeed, 
there  is  no  ophthalmia  to  which  adults  are  exposed,  in  which  ulcer 
of  the  cornea  and  onyx  are  so  frequent,  as  in  the  catarrho-rheumatic. 
If  this  disease  is  neglected  for  eight  or  ten  days,  and  especially  if 
the  patient  be  far  advanced  in  life,  we  almost  uniformly  meet  with 
one  or  other,  and  not  unfrequently  with  both  of  these  symptoms. 


344 

12.  Tlie  ulcer  is  peculiar.  It  spreads  over  the  surface,  rarely 
penetralino^  deeply  into  the  substance  of  the  cornea.  It  generally 
cicatrises  without  leaving  any  opaque  speck,  the  cornea  remaining 
merely  irregular,  as  if  part  of  it  had  been  hacked  off  with  the  lan- 
cet ;  and  of  course  vision,  from  imperfect  refraction,  is  indistinct. 
Professor  Beer  and  Mr.  Wardrop  have  described  this  kind  of  ulcer 
as  attendant  on  pure  rheumatic  ophthalmia,  but  I  have  never  seen 
it  except  in  catarrho-rheumatic  cases.  Professor  Beer  mentions 
that  it  originates  in  a  phlyctenula,  but  I  have  never  had  an  oppor- 
tunity of  seeing  any  appearance  of  this  kind.  If  the  case  continues 
to  be  neglected,  or  if  it  be  mistreated,  this  ulcer  ceases  to  be  super- 
perficial ;  the  substance  of  the  cornea  is  more  deeply  attacked,  and 
an  opaque  leucoma  will  be  the  result. 

13.  Onyx,  or  effusion  of  pus  between  the  lamellae  of  the  cornea, 
is  the  most  alarming  of  all  the  symptoms  of  this  ophthalmia.  It 
generally  commences  at  the  lower  edge  of  the  cornea,  in  shape  like 
the  white  spot  at  the  root  of  the  nails,  convex  on  its  upper  edge, 
gradually  increasing,  mounting  upwards,  separating  more  and  more 
the  lamellee  between  which  it  is  effused,  and  greatly  adding  to  the 
sufferings  of  the  patient.  It  reaches  not  unfrequently  to  such  a 
height  as  to  implicate  more  than  half  of  the  cornea.  The  pus 
of  an  onyx  in  catarrho-rheumatic  ophthalmia  is  very  rarely  ab- 
sorbed. The  cornea  becomes  ulcerated  over  the  centre  of  the 
onyx ;  the  pus  is  evacuated ;  the  ulcer  but  too  often  penetrates 
through  the  posterior  lamellae  of  the  cornea :  the  aqueous  humour 
escapes  :  the  iris  falls  forward  into  contact  with  the  ulcerated  cornea ; 
in  nine  cases  out  of  ten  these  parts  adhere  together,  and  the  result 
is  partial  or  total  staphyloma. 

14.  As  the  onyx  goes  on  advancing,  there  is  commonly  also  an 
effusion  of  lymph  into  the  pupil,  which  becomes,  first  of  all,  less 
vivid  in  its  motions,  the  colour  of  the  iris  changes,  the  pupil  be- 
comes hazy,  contracts  as  the  onyx  increases,  and  may  at  last  be 
obliterated. 

15.  In  some  cases,  the  onyx  is  accompanied  by  hypopiura  or 
effusion  of  pus  into  the  anterior  chamber.  In  other  cases,  the  onyx 
bursts  first  into  the  anterior  chamber ;  false  hypopium  is  thus  pro- 
duced, and  ultimately  the  cornea  gives  way. 

16.  If  fortunately  the  matter  of  an  onyx  be  absorbed,  albugo  re- 
mains for  a  considerable  time,  but  gradually  diminishes,  and  may 
ultimately  almost  entirely  disappear.  If  the  onyx  is  dispersed  by 
the  cornea  giving  way,  leucoma  is  the  result,  and  never  entirely 
disappears.  Staphyloma  cannot  result,  unless  the  iris  and  cornea 
have  become  partially  or  totally  adherent.  Mr.  Wardrop  has  re- 
marked, that  partial  staphyloma  generally  affects  the  inferior  half 
of  the  cornea.*  The  reason  is,  that  partial  staphyloma  is  com- 
monly the  consequence  of  onyx,  whicli  in  nine  cases  out  of  ten 
takes  place  at  the  lower  edge  of  the  cornea. 

•  Morbid  Aaatomy  of  the  Eye,    Vol  i,  p.  106.    London,  1819. 


345 

17.  In  catarrho-rheumatic  ophthalmia,  the  pulse  is  generally 
quick  and  sharp ;  the  tongue  white,  and  mouth  ill-tasted.  The 
nocturnal  pain  completely  prevents  sleep,  till  about  sunrise.  Ca- 
tarrh sometimes  attends,  and  adds  to  the  febrile  symptoms. 

18.  We  generally  find  that  the  rheumatic  symptoms  yield  first 
to  treatment ;  the  catarrhal  continuing  for  some  days  longer.  But 
in  some  cases  I  have  observed  the  reverse  ;  the  circum-orbital  pain 
continuing,  at  least  in  a  certain  degree,  after  all  the  catarrhal 
symptoms  were  gone. 

Causes.  The  causes  of  catarrho-rheumatic  ophthalmia  appear 
to  be  similar  atmospheric  influences  to  those  already  enumerated  as 
giving  rise  to  catarrhal,  and  rheumatic  ophthalmiee.  Amongst  the 
poor,  the  disease  may,  in  general,  be  traced  to  cold,  to  which  the 
patients  have  been  exposed,  particularly  during  the  night,  from 
deficient  clothing  and  want  of  proper  shelter.  Like  other  inflam- 
matory and  rheumatic  affections,  it  is  more  prevalent  during  north- 
easterly winds. 

Beer  thought  that  cold  draughts  of  air  *,  playing  upon  the  eye, 
excited  rheumatic  ophthalmia  ;  and  that  foul  air  t  caused  catarrhal 
ophthalmia.  According  to  this  view,  air  at  once  corrupted  and 
impelled  with  force  against  the  eye,  especially  when  the  head  is 
covered  with  perspiration,  will  be  the  most  likely  cause  of  catarrho- 
rheumatic  ophthalmia. 

That  the  discharge  from  the  conjunctiva  in  catarrho-rheumatic 
ophthalmia,  if  applied  to  the  conjunctiva  of  a  healthy  eye,  will 
excite  a  puro-mucous  conjunctivitis,  is  extremely  probable.  We 
can  be  at  no  loss  to  distinguish  catarrho-rheumatic  ophthalmia 
from  that  stage  of  contagious  conjunctivitis  in  which  the  inflam- 
mation spreading  inwards  to  the  deep-seated  textures  of  the  eye- 
ball, excites  sympathetic  circum-orbital  pain. 

Beer  mentions  that  catarrho-rheumatic  ophthalmia  sometimes 
occurs  in  children,  and  still  more  frequently  in  old  persons,  along 
with  suppression  of  urine.  But  he  seems  to  reject  the  conclusion  of 
some,  that  this  is  any  thing  more  than  an  accidental  coincidence ; 
and  he  gives  us  no  hope  that  diuretics  would  be  peculiarly  ser- 
viceable, even  though  they  restored  the  secretion  of  urine. t 

We  meet  with  catarrho-rheumatic  ophthalmia  much  more  fre- 
quently in  old  persons  than  in  the  young  or  middle  aged. 

Treat'm,ent.  The  successful  treatment  of  this  disease  does  not 
depend  so  much  on  any  new  remedies,  as  on  a  proper  selection  of 
some  of  the  means  already  recommended,  either  for  the  catarrhal 
or  for  the  rheumatic  ophthalmia. 

1.  Venesection  appears  to  be  as  necessary  in  the  catarrho-rheu- 
matic as  in  the  pure  rheumatic  cases ;  and  is  attended  by  as  re- 
markable relief  to  all  the  symptoms,  especially  to  the  circum-orbital 
pain.     According  to  the  severity  of  the  case,  and  the  age  and  con- 

*  Eine  kalte  Zugluft.  t  Ein  zersetzer  verdorbenor  Luftkreis. 

t  Lehre  von  den  Augenkrankheiten.    Vol.  i.  p.  310.    Wien,  1813. 

44 


346 

stitution  of  the  patient,  from  ten  to  thirty  ounces  of  blood  may  be 
taken  from  the  arm  ;  and  the  same  quantity  on  the  day  follow- 
ing, if  the  symptoms  are  not  greatly  relieved. 

2.  Leeches  to  the  temple  are  also  highly  useful,  particularly 
when  applied  soon  after  venesection. 

3.  Scarification  of  the  conjunctiva  of  the  eyelids,  is  to  be  em- 
ployed when  there  is  any  considerable  degree  of  chemosis. 

4.  Calomel  and  opium  are  productive  of  the  same  good  effects 
in  this  ophthalmia  as  in  the  pure  rheumatic.  The  dose,  and  the 
length  to  whicij  the  calomel  should  be  pushed,  are  the  same. 

5.  Opiate  jiictiofis  on  the  forehead  and  temple  are  to  be  used 
abcui   .ii  aour  before  the  expected  attack  of  circuni-orbital  pain. 

6.  Belladonna  h  to  be  applied,  so  as  to  keep  the  pupil  dilated. 

7.  Blisters  behiivd  the  ear,  or  to  the  nape  of  the  neck,  are  to  be 
employed. 

8.  Purgatives,  as  a  brisk  dose  of  calomel  and  jalap  at  the  be- 
ginning, and  a  gentle  laxative  every  morning  during  the  course  of 
the  disease,  do  good. 

9.  Sudorifics,  as  the  solution  of  acetate  of  ammonia,  dilueni 
drinks,  the  warm  pediluvium,  and  a  flannel  under-dress,  will  be 
found  useful, 

10.  Tonics,  as  sulphate  of  quina  and  the  mineral  acids,  are  to  be 
given  in  the  chronic  stage  of  the  disease. 

11.  Solution  of  nit r as  argenti.  As  in  the  catarrhal,  so  in  the 
catarrho-rheumatic  ophthalujia,  the  solution  of  from  two  to  four 
grains  of  nitras  argenti  in  an  ounce  of  distilled  water,  dropped  upon 
the  conjunctiva  once  a  day,  relieves  the  feeling  of  sand,  and  speed- 
ily removes  the  other  symptoms  of  conjunctivitis.  This  application, 
however,  has  no  effect  on  the  sclerotic  part  of  the  disease ;  and  in 
this  ophthalmia  I  should  consider  it  a  ver}'"  dangerous  mistake  to 
trust  almost  solely  to  this  remedy,  as  we  may  safely  do  in  pure  ca- 
tarrhal inflammation  of  the  eye,  and  thus  neglect  the  appropriate 
means  for  reducing  the  attendant  inflammation  of  the  sclerotica. 

12.  Vinum  opii.  Before  the  catarrhal  part  of  this  disease  is 
subdued  by  the  solution  of  nitrate  of  silver,  this  remedy  rather  ag- 
gravates the  symptoms.  After  the  conjunctivitis  and  the  acute 
sclerotitis  have  yielded,  it  operates  favourably,  as  in  the  chronic 
stage  of  the  pure  rheumatic  ophthalmia. 

13.  The  Collyrium  mariatis  hydrargyria  one  grain  to  eight 
ounces,  ^s  to  be  used,  tepid,  three  or  four  times  daily  for  bathing  the 
eye. 

14.  The  Unguentumprcecipiiati  ruhri'is  io  he  sn\e^\eA  d\oT\g 
the  edges  of  the  eyehds  at  bedtime.  These  two  remedies  are  em- 
ployed as  part  of  the  treatment  suitable  for  the  conjunctival  part  of 
the  disease. 

15.  With  respect  to  the  treatment  of  onyx,  I  would  not  recom- 
mend the  pus  effused  between  the  lamellae  of  the  cornea  to  be  evac- 
uated by  the  lancet.     In  every  case  in  which  I  have  done  thisy 


347 

partial  or  total  staphyloma  has  been  the  result.  When  I  have  left 
the  onyx  to  itself,  the  case  has  sometimes  recovered  beyond  my 
most  sanguine  expectations.  This  I  attribute  to  the  sorbefacient 
influence  of  the  calomel  over  the  lymphatic  efl\ision  into  the  pupil, 
which  aHvays  attends  extensive  onyx  ;  to  the  continued  use  of  bel- 
ladonna ;  and  to  t!ie  gradual  preparation  of  the  cornea  by  nature 
for  its  giving  way,  and  for  its  healing  up — a  preparation  which 
must  be  entiiely  defeated  when  we  venture  to  open  the  onyx  with 
ihe  knife. 


SECTION  XV. SCROFULOrS  CORNEITIS. 

The  cornea  is  liable  to  suffer  in  most  of  the  ophthalmise  which 
we  have  already  considered.  It  is  apt,  as  has  been  stated,  to  be- 
come the  seat  of  pustules  and  abscesses,  to  be  attacked  by  ulcera- 
tion, rendered  opaque,  or  almost  entirely  destroyed.  Also,  in  some 
of  the  ophthalmise  which  we  have  still  to  consider,  the  cornea  is 
occasionally  or  always  affected.  But  the  disease  to  which  we  have 
now  to  attend  is  specifically  different  from  every  other.  It  is  not  a 
puro-mucous  affection,  and  although  occurring  only  in  strumous 
subjects,  it  is  not  eruptive.  Its  development  and  progress  are  slow, 
occupying  weeks,  months,  and,  in  some  instances,  years.  It  ap- 
pears to  be  chiefly  the  conjunctival  layer  of  the  cornea,  and  the 
substance  immediately  beneath  that  layer,  which  are  affected  in 
this  disease. 

Symptoms.  I.  The  redness  is  principally  in  the  sclerotica  and 
on  tlie  surface  of  the  cornea.  The  sclerotic  redness  is  in  general 
not  very  considerable,  of  a  carmine  colour,  inclining  to  purplish,  the 
vessels  very  minute,  and  arranged  zonularly  round  the  cornea. 
Not  unfrequently  tliere  is  a  reddish  ring,  somewhat  elevated,  formed 
around  or  upon  tfie  edge  of  the  cornea,  while  red  vessels,  more  or 
less  numerous,  are  traceaiUe  over  its  surface  to  its  centre.  In  some 
cases  the  whole  cornea  is  so  much  covered,  that  it  assumes  a  red 
colour,  and  has  been  coiripared,  in  this  state,  to  a  piece  of  red  cloth  ; 
a  symptom  which  has  therefore  been  styled  pannus.  In  chronic 
cases,  the  visible  arteries  of  the  eyeball  derived  from  the  recti  mus- 
cles, are  much  dilated. 

2.  The  cornea  is  more  or  less  opaque,  and  rongh.  The  rough- 
ness frequently  resembles  the  dotting  which  might  be  produced  by 
touching  the  surface  of  the  cornea  all  over  with  the  point  of  a  pin. 
In  other  instances,  the  depressions  are  somew'hat  larger,  and  as- 
sume, under  the  magnifying  glass,  the  appearance  of  a  crowd  of 
minute  ulcers.  In  every  case,  we  find  that  the  surface  of  the  cor- 
nea has  lost  its  natural  polish  ;  and  from  this  circumstance,  even 
when  little  opacity  is  present,  the  eye  appears  dull,  and  vision  is  in- 
distinct. In  some  instances,  the  opacity  amounts  to  haziness  only  ; 
in  others,  it  consists  in  a  streaked  or  speckled  whiteness,  arising 


348 

from  depositions  of  coagulable  lymph,  with  interstices  of  clear  cor- 
nea. Not  unfrequently  the  surface  of  the  cornea  becomes  com- 
pletely and  almost  uniformly  white.  Here  and  there  we  occasion- 
ally observe  upon  it  elevated  points  of  a  yellowish  colour,  which 
never  appear  to  suppurate  or  ulcerate. 

3.  In  many  cases  of  scrofulous  corneitis,  we  find  the  cornea 
more  convex  than  natural,  or  even  in  some  degree  conical,  and 
the  aqueous  humour  superabundant ;  or,  in  other  words,  there  is 
a  certain  degree  of  hydrophthalmia. 

4.  Dilatation  of  the  pupil  not  unfrequently  attends  this  disease 
in  its  pure  state,  and,  in  many  cases,  there  is  an  evident  tenden- 
cy to  amaurosis.  But  in  other  instances  the  iris  is  inflamed  ;  and 
when  this  is  the  case,  the  pupil  is  contracted,  and  may  even,  from 
effusion  of  coagulable  lymph,  become  adherent  to  the  capsule  of 
the  lens.  In  many  cases  of  corneitis,  it  is  diflBcult  to  recognise  the 
state  of  the  iris  and  pupil,  through  the  hazy  or  speckled  cornea. 
Considerable  assistance  will  be  derived,  under  such  circumstanses, 
from  concentrating  the  light  upon  the  surface  of  the  cornea,  by 
means  of  a  double-convex  lens. 

5.  There  is  not,  in  general,  any  great  degi-ee  of  intolerance  of 
light  in  this  disease  ;  scrofulous  corneitis  presenting  in  this  respect, 
a  striking  contrast  to  phlyctenular  conjunctivitis.  This  symptom 
however,  is  variable  ;  for,  in  some  cases,  the  patient  cannot  bear 
the  light,  and  there  is  considerable  epiphora. 

6.  There  is  little  or  no  pain,  except  perhaps  in  the  commence- 
ment of  the  complaint.  After  a  time,  the  eye  falls  into  a  chronic, 
indolent  state  of  inflammation,  unattended  by  pain,  especially  after 
the  whole  cornea  has  become  opaque. 

7.  The  pulse  is  quickened,  the  patient  is  restless  in  the  night, 
and  the  skin  is  commonly  harsh  and  dry. 

8.  The  subjects  of  scrofulous  corneitis  are.  in  general,  about  the 
age  of  puberty,  and  in  the  female  the  complaint  frequently  appears 
connected  with  amenorrhcea.  In  the  female,  as  well  as  in  the 
male,  I  have,  in  many  instances,  observed  it  coincident  with  a 
peculiar  hoarseness  of  voice.  Other  strumous  symptoms  are  gen- 
erally present,  especially  swoln  lymphatic  glands  under  the  jaw, 
and  nodes  on  the  tibia. 

Corneitis  appears  to  be  the  appropriate  name  for  this  disease. 
The  cornea  is  evidently  the  chief  seat  of  the  morbid  changes. 
They  commence  apparently  in  the  cornea,  and  sometimes  are  al- 
most or  altogether  confined  to  that  part.  I  have  seen  the  opacity 
of  the  cornea  without  almost  any  of  the  sclerotic  redness. 

Causes.  The  occasional  causes  of  scrofulous  corneitis  are  ob- 
scure. I  have  known  it  arise  from  exposure  during  the  night  to 
the  glare  of  flambeaux.  Cold  has  probably  a  considerable  share  in 
producing  it ;  but  it  is  never  attended  by  the  racking  circum-orbital 
pain  of  rheumatic  sclerotitis. 

General    Treatment.      1.    Depletion.     This   may,   perhaps, 


349 

appear  to  be  but  seldom  indicated,  at  least  by  any  urgency  of  pain, 
or  signs  of  active  inflammation.  Yet  we  find  considerable  advan- 
tage from  the  application  of  leeches  to  the  neighbourhood  of  the 
eye,  especially  in  the  beginning  of  the  disease,  or  when  the  patient 
complains  of  pain  or  tension  in  the  eye  or  across  the  forehead. 
They  ought  to  be  repeated  from  time  to  time  ;  but  not  so  frequently 
as  to  reduce  too  much  the  general  strength. 

2.  Emetics  and  Purgatives  are  also  useful.  They  are  to  be  em- 
ployed according  to  the  directions  laid  down  at  pages  325  and  326. 

3.  Tartar  JEmetic,  as  a  sedative  and  alterative,  I  have  found 
decidedly  advantageous,  both  by  itself  in  doses  of  from  the  twelfth 
to  the  fourth  of  a  grain  thrice  a  day,  and  along  with  Peruvian 
bark.  This  combination  is  no  doubt  unchemical,  but  I  have  cer- 
tainly derived  more  benefit  from  these  two  medicines  given  togeth- 
er, than  from  either  of  them  singly. 

4.  Diaphoretics  are  indicated  by  the  dry  and  harsh  state  of 
the  skin.  Tartar  emetic  will  operate  favourably  on  the  skin,  and 
may  be  assisted  by  the  warm  pediluvium,  and  a  dose  of  Dover's 
powder,  at  bedtime. 

5.  Mercury,  carried  to  such  a  length  as  to  affect  the  mouth,  is 
of  great  service  in  the  treatment  of  this  disease.  It  is  not  to  be 
commenced,  however,  in  general,  till  the  acute  symptoms  have 
been  removed  by  depletion  of  different  kinds,  and  the  employment 
of  tartar  emetic  in  small  doses.  When  the  mercury  begins  to  act 
decidedly  on  the  constitution,  we  generally  find  that  the  enlarged 
vessels  on  the  cornea  contract,  and  the  newly  deposited  matter  be- 
comes absorbed.  The  clearing  of  the  cornea  conunences  around 
its  circumference,  the  favourable  change  gradually  advancing  to- 
wards the  centie.  The  best  form,  in  which  to  administer  mercury 
in  this,  as  in  some  of  the  former  ophthalmiee,  is  calomel  with  opium. 
Mercury  is  peculiarly  necessary  in  those  cases  whicii  are  attended 
with  iritis,  and  in  them  ought  to  be  employed  from  the  first. 

6.  The  Sulphate  of  Quina  exercises  an  influence  over  scrofu- 
lous corneitis,  slower  of  manifestation,  but  in  the  end  not  less  ben- 
eficial, than  that  which  the  same  medicine  displays  in  phlyctenu- 
lar ophthalmia. 

7.  Vegetable  alteratives^  as  colchicum,  sarsaparilla,  and  elm 
bark,  are  useful  remedies  in  scrofulous  corneitis,  although  inferior 
to  cinchona  and  sulphate  of  quina.  Whichever  alterative  is  se- 
lected, it  must  not  be  soon  abandoned,  although  slow  in  producing 
beneficial  effects.  Many  cases  are  under  treatment  for  a  whole 
year  or  even  longer,  before  they  perfectly  recover. 

Local  'means  of  cure.  1.  Warm  fomentations  with  poppy 
decoction,  and  exposing  the  eyes  to  the  vapour  of  hot  water  and 
laudanum,  give  great  relief  in  those  cases  in  which  the  presence 
of  light  proves  irritating. 

2.  Blisters  and  issues  on  the  neck,  behind  the  ear,  and  on  the 
temple,  are  useful  and  generally  necessary. 


350 

3.  Stimulants.  I  have  tried  many  different  remedies  of  this 
class.  They  are  admissible,  only  after  the  symptoms  of  acute  in- 
flammation are  subdaed.  On  the  whole,  most  advantage  appears 
to  be  derived  from  vinum  opii.  It  is  to  be  used  once  a  day,  after 
the  acute  symptoms  have  subsided.  Next  to  vinum  opii,  I  would 
place  the  red  precipitate  salve.  About  the  bulk  of  a  split  pea  is  to 
be  introduced  daily  between  the  Uds  and  the  eyeball,  and  then  care- 
fully rubbed  upon  the  surface  of  the  cornea  through  the  medium 
of  the  upper  lid.  From  half  a  drachm  to  a  drachm  of  red  pre- 
cipitate, triturated  along  with  an  ounce  of  white  sugar  into  an  im- 
palpable powder,  and  blown  into  the  eye  through  a  quill,  is  another 
mode  of  applying  the  same  substance.  The  lunar  caustic  solution, 
applied  in  the  usual  way,  and  a  solution  of  four  grains  of  sulphate 
of  zinc  in  an  ounce  of  water,  injected  over  the  surface  of  the  eye, 
are  attended  with  good  effects.  The  advantage  is  sometimes  very 
evident  of  employing  in  the  course  of  the  twenty-four  hours,  more 
than  one  of  these  stimulants  ;  for  example,  vinum  opii  in  the  morn- 
ing, and  red  precipitate  salve  at  bedtime. 

4.  Belladonna  is  to  be  used,  in  extract,  smeared  on  the  eyebrow 
and  upper  eyeHd,  every  evening,  when  there  are  either  evident 
symptoms,  or  even  only  a  suspicion,  of  inflammation  of  the  iris. 

5.  Evacuation  of  the  aqueous  humour  appears  to  be  indicated 
in  those  cases  in  which  there  exists  a  tendency  to  hydrophthalmia. 


SECTION  XVI. IRITIS  IN  GENERAL, 

The  discrimination  of  inflammation  of  the  iris*  has  formed  a 
highly  important  addition  to  our  knowledge  of  the  diseases  of  the 
eye.  Iritis,  (as  we  may  readily  conceive,  from  the  fact  that  the 
iris  is  nourished  by  two  arteries,  totally  unconnected  wiih  those 
which  belong  to  the  other  textures  of  the  eye,)  ofien  exists  as  inde- 
pendent of  inflammation  in  the  other  membranes  of  this  organ,  as 
conjunctivitis,  sclerotitis,  or  corneitis ;  and  on  account  of  the  im- 
portant functions  which  the  iris  performs,  as  well  as  of  the  insidious 
and  dangerous  nature  of  the  compiaint,  this  disease  is  still  more 
deserving  of  attention  than  the  ophthalmiee  already  considered. 
The  danger  chiefly  to  be  dreaded  from  iritis,  depends  on  the  fact, 
that  this  disease  partakes  of  the  nattu'e  of  adhesive  inflammation, 
so  that  in  the  course  of  a  few  days  of  a  neglected  or  misunderstood 
attack,  the  pupil  may  become  completel}''  and  irremediabl}^  oblit- 
erated by  an  effusion  of  coagulable  lyn)ph.  It  cannot  be  denied 
that  there  always  attends  upon  this  disease  a  degree  of  sclerotic 
inflammation,  that  the  anterior  hemisphere  of  the  crystalline  cap- 
sule is  in  every  case  more  or  less  affected,  and  that  but  too  often 
the  inflammatory  action  extends  to  the  choroid  and  retina.  Yet, 
the  iris  is  plainly  the  focus  of  the  diseased  action,  and  where  the 

*  Schmidt  iiber  Nachstaar  und  Iritis  nach  Staaroperationen,     Wien,  1801. 


351 

most  striking  morbid  changes  take  place.  It  is  upon  the  pupillary- 
edge  of  the  iris  that  the  disease  commences,  whence  it  spreads  to 
the  rest  of  the  iris,  to  the  capsule,  and  it  may  be,  to  the  choroid 
and  retina,  while  the  sclerotic  inflammation  appears  to  be  sympa- 
thetic. That  the  iris  is  in  many,  even  of  the  most  severe  cases, 
the  only  part  which  has  permanently  suffered,  is  proved  by  the 
fact,  that  an  artificial  pupil  is  often  found  to  restore  vision,  when 
the  natural  pupil  has  been  closed  from  inflammation,  plainly 
showing  that  the  choroid  and  retina  had  been  scarcely,  if  at  all, 
affected. 

Symftoms.  There  are  certain  symptoms  which  characterize 
inflammation  of  the  iris,  from  whatever  cause  it  proceeds. 

i.  Zonular  sclerotitis ;  fine  hair-Hke  vessels  running  in  radii 
towards  the  edge  of  tlie  cornea. 

2.  Discoloumtion  of  the  iris.  If  naturally  blue,  it  becomes  green- 
ish ;  if  dark-coloured,  reddish. 

3.  Contraction,  irregularity,  and  immobility  of  the  pupil. 

4.  Effusion  of  coagulable  lymph  into  the  pupil  and  posterior 
chamber,  and  occasionally  into  the  anterior. 

5.  Adhesions  of  the  iris,  and  especially  of  its  pupillary  edge,  to 
the  capsule  of  the  lens  ;  in  some  rare  cases,  to  the  curnea. 

6.  Dimness  of  sight,  and  sometimes  almost  total  bhndness. 

7.  Pain  in  the  eye,  and  nocturnal  circum  orbital  pain. 

In  every  case  of  iritis,  a  sufficient  number  of  these  symptoms 
will  be  met  w'ith,  to  enable  the  observer  to  decide  on  the  seat  of  the 
disease  which  is  before  him.  All  of  them  are  by  no  means  inva- 
riably present.  We  sometimes  find,  for  instance,  a  dilated  pupil  in 
iritis,  probably  from  the  coexistence  of  an)aurosis ;  and  in  some 
otherwise  well-marked  cases,  there  is  not  the  slightest  circum-orbital 
pain.  The  disease  may  also  exist  in  a  very  marked  manner,  with- 
out any  effusion  of  lymph,  or  preternatural  adhesions  of  the  iris, 
these  being  part  of  the  changes  which  take  place  only  in  the  second 
stage  of  iritis. 

Causes.  Inflammation  of  the  iris  arises  from  various  causes. 
Those  best  ascertained  are  the  following. 

1.  Exposure  to  atmospheric  changes,  and  especially  to  transitions 
from  heat  to  cold,  gives  rise  to  rheumatic  iritis. 

2.  Constitutional  syphilis,  and  syphiloid  diseases. 

3.  Strumous  inflammation  of  the  iris  occurs  along  with  cor- 
neitis,  as  a  secondary  disease;  while  in  some  less  frequent  cases, 
we  meet  with  a  strumous  iritis  which  may  be  regarded  as  pri- 
mary. 

4.  There  is  a  very  peculiar  iritis,  called  arthritic  by  the  Germans, 
who  consider  it  as  connected  with  gout. 

5.  Injuries,  as  the  operations  for  cataract. 

Besides  these  diflferent  varieties  of  iritis,  others  have  been  de- 
scribed, which  ought,  however,  in  all  likelihood,  to  be  brought  under 


352 

one  or  other  of  those  just  enumerated  ;  as,  one  from  the  action  of 
mercury,*  and  another  consequent  to  typhus  fever.t 

Degrees  and  Prognosis.  Iritis  is  met  with  of  very  different 
degrees  of  severity. +  In  slight  and  recent  cases,  complete  restora- 
tion may  be  promised  ;  in  severe  and  neglected  cases,  it  is  but 
too  often  evident  that  no  hope  can  be  held  out  of  our  being  able 
to  restore  the  power  of  vision,  or  even  to  save  the  form  of  the 
eye. 

1.  In  what  may  be  termed  the  first  degree^  the  vascularity  in 
front  of  the  sclerotica  is  often  so  shght  as  to  be  barely  perceptible, 
existing  sometimes  only  in  one  or  more  points,  or  behind  the 
upper  eyelid,  where  it  might  not  be  discovered,  unless  the  lid  was 
raised,  and  a  careful  examination  made  of  the  whole  surface  of  the 
eyeball.  The  aunulus  minor  of  the  iris,  or  narrow  ring  next  the 
pupil,  is  slightly  discoloured.  The  pupil  is  of  medium  size,  but 
wants  its  usual  clean  sharp  edge,  and  may  even  be  slightly  angular 
or  misshapen.  It  has  lost  its  jet  black  appearance,  is  discernibly 
hazy,  and  its  motions  are  limited  and  slow.  Yision  is  slightly 
obscure  and  confused,  so  that  when  the  patient  is  eagerly  engasfed 
in  business,  he  closes  the  affected  e\"e.  ?so  severe  pain  attends 
this  degree  of  the  disease,  and  there  is  scarcely  any  aversion  to 
light.  In  this  state  iritis  may  exist  for  many  weeks,  and  yet, 
by  suitable  treatment,  ma}'^  be  so  completely  overcome  that  no 
vestige  of  disease  in  the  appearance  or  action  of  the  iris  shall  re- 
main. 

2.  Litis  presents  itself  to  our  observation  much  more  frequently 
in  what  maybe  called  the  second  degree:  when  the  external  in- 
flammation of  the  eye  is  such  as  at  once  to  attract  attention.  Far- 
thest from  the  cornea,  indeed,  the  sclerotica  appears  hardly  in- 
flamed, the  trunks  only  of  the  distended  blood-vessels  being  there 
observable,  but  on  arriving  within  a  few  lines  of  the  cornea 
these  trunks  dive  into  innumerable  ramifications,  so  as  to  form 
a  compleie  radiated  zone,  or  halo  of  inflammation.  The  vessels 
seem  to  terminate  abruptly,  as  if  sinking  through  the  sclerotica, 
and  never,  in  this  degree  of  the  disease,  advance  into  or  over  the 
cornea.  The  annulus  minor,  and  partially  the  annulus  major, 
have  become  discoloured  from  the  injection  of  the  iris  with  a  super- 
abundant quantity  of  red  blood,  or  perhaps  from  effusion  of  lymph 
into  its  substance  :  and  this  change  of  colour  is  apt  to  be  perma- 
nent. The  anterior  surface  of  the  iris,  instead  of  being  smooth 
and  shining;  now  appears  dull,  puckered,  and  swoln.  particularly 

"  Travers  on  Iritis,  in  Surgical  Essays  by  Cooper  and  Travers.  Vol.  i.  p.  ^. 
London,  1518. 

t  Hewson's  observations  on  the  History  and  Treatment  of  the  Ophthalmia 
accompanving  the  Secondary  Forms  of  Lues  Venerea,  p.  36.  London,  1824. — Essay 
on  a  peculiar  inflammatory  Disease  of  theEye,  by  Wilham  Wallace  ;  in  the  Medico- 
Ciiirurffical  Transactions.     Vol.  xiv.  p.  286.     London,  1828. 

i  Essay  on  Iritis,  by  the  late  Geo.  C.  Monteath,  M.D.  in  the  Glasgow  Medical 
Journal,  Vol.  ii.  p.  43.     Glasgow,  1829. 


353 

near  the  pupil,  which  is  retracted  towards  the  lens.  The  pupil  is 
contracted,  irregular,  motionless,  and  filled  with  an  effusion  of  co- 
agulable  lymph,  which  presents  an  appearance  like  half-boiled 
white  of  egg.  Vision  is  greatly  impaired.  The  intplerance  of 
light  and  epiphora  are  considerable.  The  pain  of  the  eye  is 
pretty  constant,  and  during  the  night  is  attended  by  circum-orbital 
hemicrania.  There  are  present  the  symptoms  of  inflammatory 
fever. 

From  such  a  state  of  the  eye,  recovery  to  a  certain  extent  may 
take  place  even  without  any  very  methodical  treatment.  By  the 
use  of  proper  remedies,  the  inflammation  v/ill  gradually  be  subdued, 
and  the  efifused  lynaph  be  absorbed ;  the  contracted  pupil  will  ex- 
pand, though  probably  never  so  completely  as  to  regain  its  natural 
size  or  mobility,  and  a  tolerably  fair  state  of  vision  will  ultimately 
be  recovered.  As  the  symptoms  yield,  whitish  threads  of  organized 
lymph  will  become  evident,  binding  at  different  points  the  edge  of 
the  pupil  to  the  capsule  of  the  lens.  These  adhesions  are  capable 
of  being  elongated  in  time,  but  never  disappear  entirely,  and  neces- 
sarily impede  the  functions  of  the  iris.  In  other  cases,  the  whole 
of  the  edge  of  the  pupil  is  fringed  with  lymph,  firmly  gluing  it  to 
the  capsule,  the  centre  of  which  may  also  be  left  opaque  from  lym- 
phatic deposition,  in  which  case  the  patient  sees  only  through  the 
imperfectly  transparent  ring  left  between  the  central  opacity  of  the 
capsule,  and  the  fringed  edge  of  the  pupil.  It  sometimes  happens 
in  this  degree  of  the  disease,  that  the  posterior  surface  of  the  annulus 
minor,  which  is  covered  with  pigmentum  nigrum,  having  been 
glued  by  lymph  to  the  anterior  capsule,  the  proper  substance  of  the 
iris,  as  the  inflammation  subsides,  regains  in  a  considerable  meas- 
ure, its  power,  and  the  pupil  is  enlarged,  while  the  pigmentum  ni- 
grum remains  adherent  to  the  capsule,  and  is  seen  of  a  black  colour 
fringing  the  edge  of  the  pupil,  and  constituting  a  variety  of  what 
has  been  called  cataracta  pigmentosa. 

3.  Iritis,  in  the  third  degree,  presents  the  following  symptoms. 
The  surface  of  the  eye  is  much  more  intensely  inflamed.  The 
conjunctiva  may  be  so  much  so,  as  completely  to  mask  for  a  time 
the  zonular  redness  of  the  sclerotica.  Both  the  annulus  minor  and 
major  of  the  iris  lose  their  natural  colour.  The  anterior  surface  of 
the  iris  is  puckered,  swoln,  and  bolstered  forward  so  as  to  approach 
the  cornea,  except  its  pupillary  edge,  which  is  retracted  towards  the 
capsule  of  the  lens.  Red  vessels  and  spots  of  blood  may  sometimes 
be  discovered  on  the  surface  of  the  iris,  and  still  more  frequently  in 
the  lymph  which  occupies  the  contracted  pupil.  On  the  surface  of 
the  iris,  one  or  more  minute  elevations  of  a  yellowish  colour  make 
their  appearance,  which  in  some  cases  are  merely  spots  of  effused 
lymph,  but  in  others  prove  small  abscesses.  Pus,  discharged  from 
these,  with  lymph,  and  blood,  occupy  the  anterior  chamber.  The 
cornea  becomes  turbid,  so  as  to  resemble  a  piece  of  glass  which  has 
been  breathed  upon,  and  in  some  cases  is  dotted  over  with  minute 
45 


354  < 

brownish  spots.  Vision  is  completely,  and,  in  general,  permanently 
lost.  Flashes  of  light  in  the  eye  are  frequently  perceived  by  the 
patient,  proving  that  the  disorganization  is  extending  to  the  choroid 
and  retina^  There  is  great  intolerance  of  light,  and  copious  lach- 
rymation.  The  pain  of  the  eye  which  attends  this  third  degree  of 
iritis,  is  in  general  constant  and  excruciating,  and  attended  with 
severe  nocturnal  pain  in  the  eyebrow  and  round  the  orbit.  When 
the  case  is  attended  by  severe  and  unmitigated  pain,  especially  in 
syphilitic  cases,  there  is  reason  to  dread  the  most  serious  changes  in 
the  eye,  even  abscess  of  the  anterior  chamber,  extenuation  of  the 
sclerotica,  and  protrusion  of  the  choroid  immediately  behind  the 
cornea,  disorganization  of  the  vitreous  humour,  and  ultimately 
atrophy  of  the  eyeball. 

In  this  thiixl  degree  of  iritis,  the  prognosis  must  always  be  unfa- 
vourable, for  although  it  sometimes  happens  that  the  result  is  not 
so  fatal  to  vision  as  was  perhaps  anticipated,  especially  if  a  proper 
mode  of  treatment  is  promptly  had  recourse  to,  yet  it  is  never  the 
case  that  any  thing  near  to  a  perfect  recovery  of  the  eye  takes  place, 
under  circumstances  such  as  those  now  detailed.  The  inflamma- 
tion will  no  doubt  subside,  the  effused  lymph  and  pus  will  at  length 
be  taken  up  from  the  anterior  chamber,  but  the  pupil  will  never  be- 
come entirely  clear,  nor  regain  almost  any  degree  of  motion. 
Sometimes  no  vestige  of  pupil  can  be  distinguished,  so  much  is  the 
iris  changed  in  form  and  texture.  Most  frequently,  the  pupil  remains 
contracted  to  the  size  of  a  pin-hole,  through  which  it  sometimes 
happens  that  beyond  all  expectation  a  considerable  share  of  vision 
is  enjoyed.  In  most  cases,  however,  so  complete  a  closure  of  the 
pupil  presents  an  impenetrable  bar  to  the  transmission  of  light ; 
and,  in  many  instances,  from  the  diseased  state  of  the  choroid  and 
retina,  not  even  an  artificial  opening  in  the  iris  can  restore  vision. 

The  distinction  of  acute  and  chronic  iritis,  is  of  considerable  im- 
portance* 

We  meet  with  the  acute  disease  in  robust  individuals  of  full  habit, 
where  a  powerful  cause  has  acted  on  the  organ,  and  more  especially 
if  the  case  has  been  neglected  at  the  commencement,  or  the  cause 
has  continued  to  act.  We  find  bright  external  redness,  great  dis- 
tention of  vessels,  rapid  and  general  change  of  colour  in  the  iris,  con- 
traction of  the  pupil,  effusion  of  lymph,  dulness  of  the  cornea,  loss 
of  sight,  agonizing  pain  of  the  eye,  severe  headach,  and  conside- 
rable fever,  with  restlessness  and  want  of  sleep.  In  a  few  days 
vision  is  irreparably  lost. 

On  the  other  hand,  iritis  may  arise  so  imperceptibly,  and  proceed 
so  slowly  to  effusion  of  lymph,  to  diminution  or  even  loss  of  sight, 
that  no  pain  is  felt  in  the  part,  and  scarcely  any  redness  takes  place. 
No  alteration  is  observed  hj  others,  and  sometimes  not  even  by  the 
patient,  who  has  been  known  to  discover  the  disease  accidentally  on 
shutting  the  sound  eye,  and  finding  the  vision  of  the  other  gone. 

*  Lawrence's  Lectures  in  the  Lancet.    Vol.  x.  p.  257.    London,  1826. 


355 

Inflammation  more  readily  extends  to  the  rest  of  the  organ  in 
acute  cases,  yet  this  extension  may  equally  occur  when  the  disease 
is  chronic.  The  prognosis  must  be  drawn  from  a  combined  con- 
sideration of  the  time  the  affection  has  lasted,  the  cause  upon  which 
it  depends,  and  the  visible  effects  already  produced.  Irreparable 
injury  to  the  organ  may  occur  in  a  few  days,  when  the  inflamma- 
tion is  acute.  A  fortnight,  three  weeks,  or  a  month,  may  elapse  when 
it  is  of  ordinary  severity,  without  any  serious  mischief ;  while  a  still 
longer  duration  does  not  preclude  the  expectation  of  recovery  in  the 
most  chronic  form  of  the  complaint. 

SequelcB,  The  most  striking  sequelae  of  iritis,  are  the  changes 
which  the  pupil  undergoes  in  consequence  of  this  disease,  and  which 
are  often  of  a  permanent  kind.  Atresia  iridis  or  contraction  of 
the  pupil,  and  cataracta  hjmphatica^  or  false  cataract,  are  the  se- 
quelae of  greatest  importance. 

The  inflammatory  symptoms,  to  whatever  degree  of  violence 
they  may  have  reached,  after  an  indefinite  period  begin  to  abate. 
If  pus  and  blood  have  been  effused  into  the  anterior  chamber,  they 
are  gradually  absorbed  ;  if  an  abscess  has  formed  on  the  surface  of 
the  iris,  the  shreds  of  the  cyst,  which  for  a  time  hang  floating  in 
the  aqueous  humour,  at  length  disappear ;  and  the  anterior  cham- 
ber regains  its  transparency.  In  many  cases,  the  iris  remains  per- 
manently expanded,  and  its  motions  completely  annihilated.  Its 
greater  circle  may  in  some  measure  resume  its  natural  colour,  but 
the  lesser  continues  permanently  discoloured.  The  puckered  ap- 
pearance of  the  iris  remains.  The  pupil  is  almost  completely  closed, 
and  filled  up  by  an  ash-coloured  membrane.  The  power  of  vision 
is  entirely  lost.  This  state  is  called  by  Schmidt,  atresia  iridis 
comfleta. 

The  eye  is  not  always  left  in  so  unfavourable  a  condition.  Per- 
haps there  has  been  no  abscess,  nor  any  profuse  quantity  of  effused 
lymph.  When  the  inflammatory  symptoms  subside,  the  iris,  though 
remaining  considerably  expanded,  is  found  still  to  possess  some  de- 
gree of  mobility,  and  it  is  possible  that  its  natural  colour  may  be 
almost  completely  restored.  Though  the  pupil  is  contracted  to  a 
degree  less  than  its  medium  size,  the  coagulable  lymph,  by  which 
it  is  occupied,  is  reduced  to  the  state  of  a  fine  pseudo-membrane, 
opaque  in  most  instances  at  its  centre,  but  somewhat  transparent, 
and  perhaps  reticulated  towards  its  edge.  The  pupillary  margin 
of  the  iris  does  not  adhere  all  round  to  this  pseudo-membrane,  but 
only  at  some  points,  the  rest  being  free,  and  hence  the  pupil  is  very 
irregular,  especially  when  artificially  dilated.  Vision  under  these  cir- 
cumstances is  impaired,  not  destroyed.  This  constitutes  atresia 
iridis  incompleta. 

In  a.  third  set  of  cases,  only  part  of  the  iris  has  been  affected  with 
inflammation.  When  this  has  gone  off,  a  mere  thread  of  opaque 
matter  remains  in  the  otherwise  transparent  pupil.  By  this  thread, 
a  single  point  of  the  margin  of  the  pupil  is  kept  fixed,  while  every 


356 

other   part  is  free  and  movable.     This  is  termed  atresia  iridis 
partialis. 

Diagnosis.  The  ophthalraise  with  which  iritis  is  apt  to  be  con- 
founded, are  rheumatic,  and  catarrho-rheamatic  ophthahniee,  cor- 
neitis,  aquo-capsuhtis,  inflammation  of  the  crystalline  capsule,  and 
retinitis. 

1.  Rheumatic  ophthalmia,  catarrho-rheumatic  ophthalmia,  and 
rheumatic  iritis,  are  three  diseases  which  merge  into  one  another. 
A  degree  of  iritis  almost  invariably  attends  the  two  former  inflam- 
mations. Exactly  as  in  many  cases  of  catarrho-rheumatic  ophthal- 
mia, it  is  difficult  to  say  whether  the  disease  affects  the  conjunctiva 
more,  or  the  sclerotica,  so  it  is  often  doubtful  whether  we  should  set 
down  some  cases  of  pure  internal  ophthalmia  which  we  meet  with, 
as  examples  of  sclerotitis  or  of  iritis. 

2.  Although  there  are  present  in  corneitis  a  sclerotic  zone  of  in- 
flammation, dimness  of  vision,  and  supra-orbital  pain,  as  in  iritis, 
still  an  attentive  examination  of  the  state  of  the  cornea  itself  will 
easily  enable  us  to  distinguish  the  one  from  the  other.  The  cor- 
nea is  generally  much  more  opaque  in  corneitis  than  it  ever  becomes 
in  any  case  of  iritis,  the  opacity  is  speckled  and  streaked  in  a  pecu- 
liar manner,  and  partially  covered  by  the  ramifications  of  red  vessels. 
If  through  the  cornea  we  observe  the  pupil  moving  briskly,  accord- 
ing to  the  various  degrees  of  light  to  which  the  eye  is  exposed,  we 
may  conclude  that  the  case  is  one  of  pure  corneitis  ;  but  as  has  al- 
ready been  mentioned,  we  meet  with  cases  in  which  iritis  and  cor- 
neitis are  conjoined,  and  as  the  cornea  is  often  too  dim  to  permit  of 
the  iris  itself  being  distinctly  seen,  we  are  obhged  to  judge  of  the 
existence  of  this  combination  by  the  severity  of  the  pain,  and  the 
size  and  mobility  of  the  pupil.  The  circum-orbital  pain,  and  the 
pain  in  the  eye  are  more  severe  when  both  iritis  and  corneitis  are 
present,  than  in  simple  inflammation  of  the  cornea ;  and  the  exter- 
nal opacity  is  rarely  such  as  altogether  to  prevent  us  from  judging 
of  the  state  of  the  pupil.  If  it  be  contracted  and  fixed,  iritis  is  un- 
doubtedly present. 

3.  In  inflammation  of  the  lining  membrane  of  the  cornea,  or 
aqueous  capsule,  there  is  radiated  sclerotitis,  seldom,  however,  sur- 
rounding the  whole  cornea,  with  dull  aching  pain  in  the  fore- 
head, so  that  in  these  respects  there  is  a  resemblance  to  iritis. 
The  opacities  on  the  internal  surface  of  the  cornea  are  very  di- 
agnostic in  aquo-capsulitis  ;  they  are  milky  spots  producing  a  pecu- 
liar mottled  appearance,  very  unlike  any  of  the  common  specks  of 
the  cornea.  In  some  cases,  however,  of  this  disease,  there  takes 
place  an  eff"usion  of  coagulable  lymph,  which,  mingling  with  the 
aqueous  humour,  m_ay  produce  an  appearance  somewhat  closer  to 
the  symptoms  of  severe  iritis.  Indeed  it  sometimes  happens  after 
keratonyxis,  or  the  operation  of  division  of  the  cataract  through 
the  cornea,  that  iritis  occurs  in  conjunction  with  aquo-capsulitis. 

4.  The  disease  most  resembhng  iritis  is  inflammation  of  the 


357 

crystalline  capsule,  first  accurately  described  by  Professor  Wal- 
ther.  Partial  zonular  sclerotitis,  discoloured  iris,  nebulous,  con- 
tracted, and  fixed  pupil,  and  even  adhesions  between  the  iris  and 
the  capsule,  are  present  in  this  disease  ;  and  yet  it  appears  spe- 
cifically different  from  iritis.  The  pain  which  attends  it  is  less, 
it  is  generally  limited  to  one  spot  of  the  capsule,  it  is  slower  in  its 
progress  than  almost  any  case  of  iritis  ever  is,  and  it  is  much  less 
under  the  influence  of  remedies  of  any  kiad.  It  cannot  be  denied, 
however,  that  inflammation  of  the  crystalline  capsule  is  always 
accompanied  by  some  degree  of  iritis, 

5.  Retinitis  resembles  iritis  in  the  appearance  of  the  external 
inflammation  by  which  it  is  attended,  and  in  the  closure  of  the 
pupil  which  it  speedily  produces  ;  but  its  attack  is  more  sudden, 
its  progress  much  more  rapid,  the  pain  of  the  head  by  which  it  is 
attended,  still  more  insufferable,  while  vision,  and  even  the  per- 
ception of  hght,  are  destroyed  much  earlier,  and  even  before  the 
pupil  closes. 

General  Cure  of  Iritis.  The  chief  indications  in  this  disease 
are — 1.  To  subdue  the  inflammation.  II.  To  prevent  the  effusion 
of  coagulable  lymph,  or  to  promote  its  absorption  if  already  effused. 
III.  To  preserve  the  pupil  entire,  or  to  dilate  it,  if  already  con- 
tracted. IV.  To  assuage  the  attending  pain.  To  fulfil  these  in- 
dications we  have  recourse  to  such  remedies  as  the  following, 

1.  Blood-letting  must  in  no  case  be  neglected,  and  when  the 
patient  is  robust  and  the  inflammation  severe,  must  be  vigorously 
employed.  Local  bleeding  is  by  no  means  adequate  to  remove 
iritis  even  of  moderate  severity.  General  bleeding  must  be  pre- 
mised and  repeated  till  the  constitutional  irritation  is  abated. 
Leeches  may  then  be  applied  freely  round  the  eye,  and  repeated 
every  day  or  every  second  day,  till  the  inflammation  is  subdued. 
Scarification  of  the  conjunctiva  is  useless,  or  even  hurtful,   in  iritis. 

2.  Purging^  the  use  of  diuretics,  a  spare  and  cool  diet,  confine- 
ment within  doors,  rest  of  the  whole  body,  and  the  shading  of  both 
eyes  from  the  light,  will  be  found  powerful  auxiliaries, 

3.  Antimoni/,  and  other  nauseants,  prove  useful  in  two  ways. 
They  moderate  the  circulation,  and  render  the  system  more  sus- 
ceptible of  the  influence  of  mercury, 

4.  Opiates  are  in  general  imperiously  demanded  in  iritis,  by  the 
severity  of  the  nocturnal  circum-orbital  pain,  as  well  as  by  the  dis- 
tress which  the  patient  experiences  in  the  eye  itself, 

5.  Mercury  given  so  as  to  affect  the  constitution,  is  a  most 
valuable  remedy  in  iritis.  By  subduing  the  inflammation,  it  both 
prevents  the  effusion  of  coagulable  lymph  from  the  iris ;  and  if 
that  substance  is  already  effused,  powerfully  promotes  its  absorp- 
tion,* ' 

*  The  influence  of  mercury,  alone,  or  combined  with  opium,  in  ophthalmia,  has 
long  been  generally  known.     See  Warner  Plenck,  his  plagiarist  Rowley,  &c. 

The  fojbwing  passage  shows  distinctly  that  Beer  was  well  acquainted  both  with 


358 

6.  Turpentine  has  lately  been  recommended  as  a  remedy,  which^ 
taken  internally  in  cases  of  iritis,  displays  properties  analogous  to 
those  of  mercury.* 

7.  Blisters  behind  the  ears,  or  to  the  nape  of  the  neck,  are  of 
material  use  after  sufficient  loss  of  blood. 

8.  Belladonna,  in  the  first  degree  of  iritis,  speedily  expands  the 
pupil ;  in  the  second  and  third  degrees,  it  has  no  apparent  effect 
till  the  inflammation  is  considerably  subdued  by  bloodletting  and 
the  use  of  mercury.  It  ought  to  be  employed  in  every  case  and  in 
all  stages  of  the  disease.  The  mode  of  employing  it  is  in  extract, 
smeared  on  the  eyebrow  and  upper  eyelid  every  evening.  As  it 
is  during  the  night  that  the  disease  appears  to  make  most  progress, 
and  as  during  sleep  there  is  a  natural  closure  of  the  pupil,  which 
must  favour  the  permanent  contraction  which  iritis  tends  to  pro- 
duce, the  evening  is  evidently  the  most  proper  time  to  apply  the 
belladonna.!  As  soon  as  the  inflammation  has  subsided  in  any 
considerable  degree,  and  the  fibres  of  the  iris  have  become  some- 
what relieved  from  the  eff'used  lymph,  the  pupil  will  begin  to  ex- 
pand ;  and  even  in  neglected  cases,  where  the  pupil  has  been 
allowed  to  become  almost  obliterated,  the  continued  use  of  bella- 
donna for  many  months  is  sometimes  attended  by  a  gradual  dila- 
tation, and  a  corresponding  improvement  in  vision.  I  have  already 
referred  to  an  occasional  effect  of  belladonna,  which  may  perhaps 
appear  to  some  to  afford  ground  for  objecting  to  its  use  in  the  acute 
stage  of  iritis,  namely,  its  operation  on  the  proper  substance  of  the 
iris,  so  as  to  dilate  the  pupil,  but  at  the  same  time  to  leave  the  pig- 
mentum  nigrum,  or  uvea,  attached  to  the  capsule  of  the  lens, 
whence  it  never  afterwards  appears  to  separate.  That  this  tearing 
of  the  iris  from  the  uvea  does  occasionally  happen  from  the  in- 
fluence of  belladonna,  is,  I  believe,  undeniable.  It  is,  however,  a 
rare  occurrence ;  very  rare,  if  proper  nieans  are  promptly  adopted 
to  subdue  the  inflammation  ;  more  apt  to  occur  if  the  case  is  trusted, 
as  some  have  recommended,  to  mercury,  without  bloodletting. 
After  taking  away  blood,  I  should  never  hesitate  to  appl}^  belladon- 
na. 

The  above-mentioned  remedies  are  suited,  more  or  less,  to  every 

the  effects  of  iritis,  before  Schmidt's  work  was  published,  and  also  with  the  power  of 
mercury,  in  preventing  effusion  of  lymph  into  the  pupil.  "Esfreute  niich  ungemein, 
auch  hier  schon  nach  Tf  ar?ier  das  Calomel  bey  der  AugenentzOndung  empfohlen  gefun- 
den  zu  haben;  den  es  giebt  gewiss  kein  wirksameres  Mittel  gegen  die  heftigste  Phlegmone 
und  gegen  die  Gefahr  der  Eiterung  und  das  Ausschwitzen  der  Lymphe,  als  dieses  ; — 
versteht  sich,  wenn  die  nothigen  Blutausleerungen  vorausgegangen  sind. — Ich  unter- 
sttltze  und  befordere  diese  vortrefliche  Wirkung  in  hartnackigen  Fallen  noch  durch 
aussere  Einreibungen  des  CLuecksilbers  in  der  Gegend  der  Augenbraunen,  und  sehe 
seit  der  Zeit,  als  ich  mich  deiser  Methode  bediene,  auch  bey  der  heftigsten  Entztlndung 
keine  Eiterung,  oder  keinen  Staar  vom  Ausschwitzen  der  Lymphe  mehr  entstehen. 
Wirklich  ein  ausserst  wichtiger  Vortheil  fUr  den  Praktiker.''  Bibliotheca  Ophtalmi- 
ca,  Vol.  ii.  p.  85.     Vindobon£e,  1799.     See  also  Vol.  i.  p.  55. 

*  Observations  on  the  efficacy  of  Turpentine  in  the  venereal  and  other  deep-seated 
Inflammation  of  the  eye  ;  by  HughCarmichael.     Dublin,  1829. 

t  London  Medical  and  Physical  Journal,  Vol.  liv.  p.  113.     London,  1825. 


359 

kind  of  iritis  :  but,  of  course,  peculiar  modifications  in  the  treatment 
will  be  necessary  according  to  the  different  causes  of  the  disease, 
whether  these  be  syphilitic,  scrofulous,  arthritic,  or  of  whatever  other 
nature,  and  according  to  the  different  symptoms  which  each  spe- 
cies presents. 


SECTION    XVII. RHEUMATIC  IRITIS. 

It  hds  already  been  mentioned,  that  attendant  on  rheumatic  and 
catarrho-rheumatic  ophthalmia,  there  is  in  general,  a  degree  of  iri- 
tis ;  while  in  the  first  of  these  two  diseases  the  chief  seat  of  the  in- 
flammation is  the  sclerotica,  and  the  conjunctiva  and  sclerotica  in 
the  second.  There  is  a  third  set  of  cases  arising,  like  the  two  oph- 
thalmias just  referred  to,  from  exposure  to  atmospheric  changes,  in 
which  the  iris  is  all  along  the  part  principally  affected,  and  in  which 
the  attack  is  sudden  ;  in  this  last  respect  resembhng  other  diseases 
caused  by  external  influences,  and  differing  from  those,  which, 
originating  entirely  in  some  constitutional  or  internal  cause,  ad- 
vance slowly  and  insidiously.  Not  unfrequently,  both  eyes  are 
simultaneously  affected  with  this  disease,  and  with  nearly  equal 
severity.  In  other  cases,  only  one  eye  is  inflamed,  or  the  one  much 
more  severely  than  the  other. 

Local  symptoms.  In  rheumatic  iritis,  changes  occur  even  at 
the  very  commencement  of  the  disease,  indicative  of  the  peculiar 
seat  of  the  inflammation.  These  changes  uniformly  commence 
upon  the  edge  of  the  pupil,  whence  they  extend  gradually  towards 
the  ciliary  circumference  of  the  iris.  The  pupil  is  first  of  all  seen 
to  be  contracted,  the  motions  of  the  iris  impeded,  and  the  pupillary 
opening  deprived  of  the  bright  black  colour  which  it  naturally 
possesses.  The  colour  of  the  iris  is  next  observed  to  undergo  a 
change  ;  first,  in  the  lesser  circle,  which  becomes  of  a  darker  hue, 
and  afterwards  in  the  greater,  which  grows  green,  if  it  had  been 
greyish  or  blue,  and  reddish,  if  it  had  been  brown  or  black.  This 
change  of  colour,  is  a  never-failing  index  of  the  substance  of  the 
iris  being  inflamed,  and,  as  has  already  been  mentioned,  is  apt  to 
continue  after  all  the  other  symptoms  of  iritis  have  been  subdued. 
As  soon  as  it  is  observed  to  have  taken  place  to  a  considerable  de- 
gree in  the  greater  circle,  the  iris  swells,  and  projects  towards  the 
cornea,  while  the  pupillary  margin,  losing  its  sharply  defined  edge, 
seems  somewhat  thickened,  and  is  turned  back  towards  the  capsule 
of  the  lens. 

The  redness  accompanying  these  changes,  is  by  no  means  con- 
siderable, and  is  at  first  confined  to  the  sclerotic  coat,  in  which  a 
number  of  very  minute  rose-red  vessels  are  seen,  running  in  straight 
lines  towards  the  cornea.  By  and  by,  the  redness  increases,  and 
is  seen  to  arise  partly  from  vessels  developed  in  the  conjunctiva. 
The  vascularity  is  greatest  round  the  cornea ;  towards  the  folds  of 
the  conjunctiva,  it  fades  away. 


360 

There  is  pain  in  the  eye,  in  many  cases  severe  and  pulsative, 
and  increased  on  motion  of  the  organ  ;  pain  in  the  eyebrow ;  and 
circum-orbital  nocturnal  paia,  similar  to  what  is  met  with  in  rheu- 
matic sclerotitis. 

If  the  disease  is  not  checked,  the  pupil  is  observed  to  lose  its 
circular  form,  becoming  irregular,  and  at  tlie  same  time  presenting 
a  greyish  appearance.  Examined  through  a  magnifying  glass  of 
short  focus,  or  even  by  merely  concentrating  the  rays  of  light  upon 
the  pupil  through  a  double-convex  lens,  this  greyish  appearance  is 
seen  to  be  produced  by  a  substance  very  like  a  cobweb,  which  an 
experienced  eye  instantly  recognises  as  a  delicate  flake  of  coagu- 
lable  lymph.  Into  this,  the  processes  or  dentations  of  the  irregular 
pupillary  margin  of  the  iris  seem  to  shoot,  and  it  is  afterwards 
found  that  at  these  points,  adhesions  between  the  iris  and  capsule 
are  apt  to  be  established.  It  is  owing  to  these  adhesions,  that  the 
patient,  whose  vision  has  been  all  along  indistinct,  sometimes  com- 
plains of  now  being  able  to  see  only  one  side  or  part  of  an  object. 

The  effusion  of  lymph  into  the  pupil  continues  to  increase.  It 
takes  place  likewise  behind  the  iris,  so  that  adhesions  are  formed 
between  the  uvea  and  the  capsule  of  the  lens.  The  quantity  of 
lymph  effused  is  sometimes  so  great,  as  to  fall  down  in  a  curd-hke 
form,  into  the  anterior  chamber. 

By  this  time,  the  morbid  sensibility  to  light  which  prevailed  at 
the  commencement  of  the  disease,  is  diminished ;  the  powers  of 
vision  become  gradually  more  and  more  limited,  and  at  length 
little  more  than  the  perception  of  light  remains.  Not  unfrequently, 
the  lymph  occupying  the  contracted  pupil,  gives  rise  to  the  sensa- 
tion of  a  black  spot,  like  a  fly,  or  of  several  black  or  hazy  spots, 
placed  as  it  were  at  some  distance  before  the  eye,  and  partially 
intercepting  the  view  of  the  objects  situated  before  or  to  one  side 
of  the  patient. 

As  the  disease  goes  on,  the  cornea  loses  somewhat  of  its  pecuhar 
brilliancy,  and  in  some  cases,  very  striking  changes  take  place  on 
the  anterior  surface  of  the  iris.  Spots  of  lymph  occasionally  form 
upon  it ;  while,  in  other  cases,  lymph  appears  to  be  deposited  in  the 
substance  of  the  iris,  for  while  it  projects  more  and  more  towards 
the  cornea,  its  fibres  get  collected  into  bundles,  givdng  to  its  surface 
a  peculiar  plaited  or  puckered  appearance.  In  some  cases,  one  or 
more  yellowish-red  elevations  form  on  the  anterior  surface  of  the 
iris,  most  frequently  about  the  union  of  its  greater  and  lesser  circles. 
Small  at  first,  such  an  elevation  gradually  enlarges,  projects  towards 
the  cornea,  and  is  at  length  distinctly  seen  to  be  a  cyst  containing 
pus,  which,  finally  bursting,  discharges  its  contents  into  the  anterior 
chamber  and  thus  gives  rise  to  spurious  hypopium.  A  small  quan- 
tity of  blood  is  sometimes  extravasated  at  the  same  time  into  that 
cavity. 

Such  is  the  general  history  of  a  neglected  case  of  rheumatic 
iritis.     We  meet,  of  course,  with  many  degrees  of  severity  in  this 


361 

disease ;  while  its  sequelae  are  varied,  as  has  been  described  in  the 
last  section,  and  more  or  less  detrimental  to  vision.  The  inflam- 
mation will  at  length  subside,  even  though  no  remedies  are  em- 
ployed ;  but,  in  such  cases,  vision  will  in  general  be  lost. 

Constitutional  symptoms.  Like  rheumatic  sclerotitis,  this  in- 
flammation of  the  iris  may  attack  an  individual  who  has  never 
suftered  from  rheumatism  in  any  other  part  of  the  body.  Not 
unfrequently,  however,  the  subjects  of  this  disease  have  long  been 
subject  to  other  rheumatic  affections,  although  the  iritis  appears  in 
every  case  to  be  excited  by  some  new  exposure  to  cold,  and  never, 
as  far  as  I  have  seen,  to  be  metastatic.  Thirst,  whiteness  of  the 
tongue,  and  accelerated  pulse  attend  an  attack  of  rheumatic  iritis. 
The  bowels  are  frequently  confined,  and  there  is  occasionally  a 
disposition  to  nausea. 

Causes.  These  are  the  same  with  those  already  enumerated  as 
producing  rheumatic  ophthalmia.  Some  people  of  confirmed  rheu- 
matic habits  suffer  exceedingly  from  one  or  more  attacks  of  thiiS 
disease  every  year,  each  succeeding  attack  leaving  the  eye  in  a 
worse  state,  till  at  length  vision  is  destroyed. 

This  iritis  frequently  occurs  during,  or  after  the  use  of  mercury, 
in  consequence  of  this  medicine  powerfully  predisposing  the  whole 
body,  to  suffer  from  the  exciting  causes  of  rheumatic  inflammation. 

Complication  with  amaurosis.  This  is  a  complication  by 
no  means  of  very  rare  occurrence.  It  is  particularly  frequent 
after  typhus  fever,  a  disease,  which  it  is  well  known,  is  extremely 
apt  to  leave  the  retina  more  or  less  insensible,  and  the  pupil  dilated. 

Mr.  Wallace  has  described  the  complication  of  amaurosis  with 
iritis  after  typhus  fever,  as  presenting  two  distinct  stages.  During 
the  first  stage,  there  exists  amaurotic  symptoms  alone  ;  in  the  sec- 
ond, symptoms  of  inflammation  are  superadded.  The  length  of 
time  that  the  amaurotic  symptoms  continue,  before  the  occurrence 
of  any  visible  appearance  of  inflammation,  is  extremely  uncertain, 
as  also  the  period  after  fever  at  which  the  amaurotic  symptoms 
commence.  On  many  occasions,  the  amaurotic  symptoms,  particu- 
larly a  slight  dimness  of  vision,  with  muscse  volitantes,  have  com- 
menced at  or  even  before  the  time  of  convalescence  from  fever,  and 
yet  the  inflammatory  stage  has  not  supervened  for  weeks  or  even 
months  ;  while  on  other  occasions  the  dimness  of  vision  has  not 
commenced  for  several  days,  weeks,  or  even  months,  after  the  fe- 
brile attack,  and  has  then  been  immediately  followed  by  the  symp- 
toms of  inflammation.  Mr.  W.  never  saw  a  case  in  which,  upon 
strict  inquiry,  amaurotic  symptoms,  more  or  less  strongly  marked, 
had  not  preceded  the  inflammatory  symptoms.  He  also  observed 
that  the  inflammatory  symptoms  uniformly  subsided  a  longer  or 
shorter  time  before  the  amaurotic  symptoms  disappeared,  and  often 
before  they  had  even  diminished  in  severity.* 

"*  Medico-Chirurgical  Transactions,  Vol.  xiv.  p.  294.     London,  1828. 

46 


362 

Treatment.  1.  Blood-letting.  The  degree  of  synocha  which 
is  present  in  rheumatic  iritis,  and  the  effects  of  depletion  on  the  lo- 
cal symptoms,  must  guide  us  as  to  the  extent  and  kind  of  bleeding. 
Repeated  venesection  is  almost  always  necessary,  followed  by  the 
liberal  application  of  leeches  round  the  eye. 

2.  Mercury.  Scarcely  is  the  mouth  affected  by  the  use  of  cal- 
omel and  opium,  when  we  observe  the  most  marked  abatement  of 
the  symptoms.  It  cannot  be  denied,  however,  that  unless  the  pa- 
tient be  careful  to  avoid  new  exposure  to  cold,  the  mercurial  treat- 
ment may  prove  actually  more  injurious  than  beneficial.  He  ought 
to  leave  off  his  usual  employment,  confine  himself  within  doors^ 
and,  if  the  case  is  severe,  keep  his  bed.  Unless  this  is  done,  the 
disease  is  apt  to  recur  with  redoubled  fury,  even  from  such  slight 
causes  as  changing  the  head-dress,  passing  from  one  room  to 
another,  and  the  hke.  It  is  sometimes  a  question  of  difficulty, 
when  the  patient  is  poor,  and  unprovided  with  proper  clothing  and 
shelter,  whether  we  should  give  mercury  at  all,  unless  the  patient 
be  admitted  into  an  hospital.  We  are  almost  certain  by  its  omis- 
sion to  ruin  the  eye,  and  by  its  exhibition  seriously  to  endanger 
the  general  health.  The  patient's  room  should  be  darkened,  and 
have  a  moderate  fire  in  it  in  winter.  A  band  of  flannel  should 
be  constantly  worn  around  the  head,  and  several  folds  of  linen 
over  the  eye,  to  prevent  the  bad  effects  of  atmospheric  changes. 

3.  Turpentine,  as  recommended  by  Mr.  Carmichael  for  syphi- 
litic iritis,  may  be  tried  with  some  hope  of  success.  See  next  sec- 
tion. 

4.  Rest,  and  the  antiphlogistic  regimen,  must  be  strictly  en- 
joined. 

5.  Opiates.  If  we  give  calomel,  we  combine  it  with  opium, 
and  exhibit  it  at  bedtime.  If  we  refrain  from  the  internal  use  of 
mercury,  a  powerful  opiate  ought  to  be  given  every  night,  to  as- 
suage the  pain.  Friction  of  the  head  with  warm  laudanum,  is 
also  to  be  employed,  or  friction  with  mercurial  ointment  containing 
opium.  Should  this,  along  with  the  opiate  taken  internally,  fail  to 
prevent  the  nocturnal  attack  of  pain  in  the  eye  and  round  the  orbit, 
considerable  relief  may  be  obtained  by  fomenting  the  eyelids  and 
parts  around  with  flannel  cloths,  wrung  out  of  poppy  decoction, 
care  being  taken  to  dry  the  parts  well  as  soon  as  the  fomentation  is 
finished,  and  then  to  replace  the  iinen  compress,  previously  heated 
at  the  fire. 

6.  Purgatives.  As  much  of  the  sulphate  of  magnesia  as  will 
open  the  bowels  moderately,  is  to  be  given  every  morning. 

7.  Diuretics.  Small  doses  of  nitre  and  cream  of  tartar,  every 
two  or  three  liours,  are  useful. 

8.  Diaphoretics  are  of  service,  but  are  liable  to  the  same  objec- 
tion as  mercury.  Unless  the  patient  can  protect  himself  from  cold, 
Ihey  ought  to  be  avoided. 

9.  Cinchona  is  undoubtedly  a  remedy  of  considerable  utility  in 


363 

the  treatment  of  rheumatic  iritis.  I  am  as  much  opposed,  howev- 
er, to  the  idea  of  trusting  to  it  almost  alone,  as  I  am  to  the  plan  of 
confiding  solely  in  the  antiphlogistic  and  sorbefacient  powers  of 
mercury  in  this  disease,  to  the  neglect  of  blood-letting,  and  other 
depletory  means  of  cure.  In  an  inflammation  oi  so  dangerous  a 
nature  as  iritis,  we  should  be  ready  to  avail  ourselves  of  every  rem- 
edy, and  never  allow  ourselves  to  be  beguiled  into  bad  practice,  by 
an  affectation  of  simphcity. 

It  is  chiefly  in  the  combined  cases  of  amaurosis  and  iritis  after 
typhus  fever,  that  cinchona  has  been  found  useful ;  and  it  is  upon 
the  iritis,  more  than  upon  the  amaurosis,  that  it  has  been  found 
to  exercise  its  beneficial  influence.  Notwithstanding  the  strong 
testimony  of  Mr.  Wallace  in  favour  of  commencing  the  treatment 
of  such  cases  with  cinchona,  I  confess  I  am  not  convinced  of  the 
propriety  of  omitting  the  use  of  depletion,  and  mercury,  in  such 
cases  of  iritis  as  that  gentleman  has  described.  Certainly  the  dis- 
ease will  not  be  aggravated  by  employing  these  means.  Indeed 
Mr.  W.  cannot  deny  the  fact,  that  cases  of  the  very  same  kind 
as  those  which  he  has  recorded,  were  cured  by  mercury  under 
the  care  of  Mr.  Hewson.*  After  the  acute  symptoms  are  subdued 
by  depletion  and  mercury,  I  have  no  doubt  that  cinchona,  in  the 
form  either  of  bark,  or  of  sulphate  of  quina,  will  be  found  highly 
useful,  not  only  in  the  particular  variety  of  iritis  which  is  so  apt 
to  follow  typhus  fever,  but  in  ordinary  cases  of  rheumatic  iritis,  and 
especially  when  the  patient  is  of  a  strumous  constitution.  I  may 
here  observe,  that  I  am  inchned  to  suspect  the  existence  of  lingering 
congestion  in  the  head,  in  the  cases  of  combined  iritis  and  amau- 
rosis, which  succeed  to  typhus  fever.  In  a  case  of  this  kind, 
which  I  lately  treated,  I  found  that  little  or  no  effect  was  produced 
by  repeated  leeching,  the  use  of  calomel  with  opium,  and  the  ap- 
plication of  belladonna.  There  was  all  along  slight  pain  in  the 
eye,  with  zonular  redness,  irregular  pupil,  and  dimness  of  sight. 
Thirty  ounces  of  blood  were  taken  from  the  arm.  The  patient 
felt  immediately  easier.  The  second  cupful  was  observed  to  be 
consideiably  more  buffy  than  the  first.  Next  morning,  the  pupil 
was  widely  dilated  in  consequence  of  the  action  of  the  belladonna, 
the  redness  much  less,  the  pain  completely  gone,  and  vision  greatly 
improved. 

10.  Blisters  behind  the  ear,  on  the  temple,  and  on  the  back 
of  the  neck,  are  of  more  service  in  the  rheumatic,  than  in  any 
other  iritis.  To  produce  a  more  moderate  degree  of  counter-irrita- 
tion, the  laudanum  with  which  the  head  is  rubbed,  when  the  noc- 
turnal pain  threatens  to  begin,  may  be  mixed  with  an  equal  quan- 
tity of  tincture  of  cantharides. 

11.  Belladonna  should  be  freely  applied  every  evening  to  the 
eyebrow  and  upper  eyelid. 

*  Hewson's  Observations  on  the  History  and  Treatment  of  the  Ophthalmia  accom- 
panying the  Secondary  Forms  of  Lues  Venerea,  p.  109.    London,  1824. 


364 

12,  Vinum  opii  is  serviceable  in  the  decline  of  this  disease. 
Any  other  application  to  the  eye  itself  in  the  form  of  coUyrium, 
drop,  or  salve,  is  worse  than  useless. 

Prevention.  Those  who  are  subject  to  rheumatic  iritis,  must 
carefully  avoid  the  exciting  causes  ;  especially,  sudden  transitions 
from  heat  to  cold,  violent  exercises,  crowded  assembhes,  late  hours, 
card-playing,  excess  in  eating  and  drinking,  and  the  like.  Sea- 
bathing in  summer  is  sometimes  of  use  in  preventing  relapses. 
Removal  to  a  southern  climate  during  the  winter,  may  be  the 
means  of  saving  a  patient  from  his  usual  attack. 


SECTION  XVIII. —  SYPHILITIC  IRITIS. 

It  is  a  fact,  which  places  in  a  very  striking  light  the  propriety  of 
bestowing  a  concentrated  attention  on  the  diseases  of  the  eye,  that 
while  syphilitic  ophthalmia  remained  so  little  known  to  many  of 
the  most  eminent  surgeons  of  this  and  other  countries,*  that  some 
of  them  even  doubted  its  existence,  its  symptoms  and  treatment 
had  long  been  familiar  to  the  ophthalmologists  of  Germany. 

Like  other  secondary  syphihtic  affections,  iritis  is  insidious  in 
its  early  stage,  but  after  a  time  rapidly  and  extensively  destructive. 
If  left  to  itself,  it  does  not  fail  to  disorganize  almost  every  texture 
of  the  eyebal],  commencing  with  the  iris,  and  extending  its  de- 
structive influence  to  the  choroid  and  retina,  the  vitreous  humour, 
and  even  the  cornea  and  sclerotica. 

Local  syinptoms.  The  general  diagnostic  symptoms  of  iritis, 
as  enumerated  at  page  350,  are  in  general  well  marked  in  the  sy- 
philitic species  ;  but  it  is  important  to  observe,  that  in  the  incipient 
stage,  they  are  sometimes  veiy  slight,  the  syphilitic  differing  in 
this  respect  from  the  rheumatic  iritis,  which  from  the  external  na- 
ture and  sudden  action  of  its  exciting  cause,  is  generally  charac- 
terised even  from  the  commencement  by  signs  which  can  scarcely 
be  overlooked  or  mistaken.  In  the  syphilitic  species,  on  the  other 
hand,  the  redness  is  sometimes  for  a  length  of  time  scattered  or 
fcLScicular,  rather  than  zonular,  and  the  changes  in  the  appearance 
of  the  iris  and  pupil  very  slight.  This  shows  the  necessity,  in 
suspected  cases,  perhaps  I  ought  to  say  in  all  cases  of  iritis,  of  ex- 
amining with  attention  the  state  of  the  skin  and  throat,  and  in- 
quiring into  the  history  of  the  patient's  previous  health.  We  almost 
always  find  the  remains  of  a  syphilitic  eruption,  or  sore  throat,  to 
attend  the  accession  of  syphilitic  inflammation  of  the  iris  ;  in  many 
cases,  this  ophthalmia  is  coexistent  wAh.  active  secondar)^  symp- 
toms in  various  textures  of  the  body  ;  and  in  all  instances,  the 
history  of  the  patient's  health  will  throw  a  degree  of  hght  on  the 
affection  of  the  eye^  which  may  be  the  means  of  preventing  the 
most  disastrous  consequences. 

*  Hunter,  Scarpa,  B.  Bell,  Howard,  Pearson,  &c. 


365 

It  is  unnecessary  to  repeat  any  description  of  the  zonular  redness, 
'discolouration  of  the  iris,  contraction,  irregularity,  and  immobility  of 
the  pupil,  effusion  of  lymph,  and  other  general  symptoms  of  iritis, 
as  they  occur  in  the  syphihtic  species.  In  none  of  these  symptoms, 
nor  in  the  dimness  of  sight  and  pain  xvhich  attend  them,  is  there 
any  thing  that  I  know  of,  really  diagnostic  ;  although  some  authors 
have  imagined,  that  they  had  discovered  in  some  of  these  symp- 
toms, peculiarities,  upon  which  a  diagnosis  could  be  founded.  The 
fact,  however,  that  even  directly  contrary  appearances  have  been 
enumerated  as  diagnostic  of  syphilitic  iritis,  shews,  that  to  distin- 
guish this  species  from  the  rheumatic,  something  more  must  be 
taken  into  account,  than  any  differences  which  may  be  observed  in 
the  general  symptoms  of  the  disease. 

Beer  has  described  two  remarkable  local  appearances  as  charac- 
teristic of  syphilitic  iritis ;  viz.  displacement  of  the  pupil,  and  con- 
dylomata sprouting  from  the  iris. 

The  first  of  these  consists  in  a  gradual  movement  of  the  pupil 
upwards  and  inwards,  so  that  instead  of  being  placed,  as  it  is  in 
health,  nearly  in  the  centre  of  the  iris,  it  comes  to  be  situated  con- 
siderably closer  to  the  upper  and  inner  edge  of  that  membrane. 
This  displacement  I  have  seen  in  chronic  rheumatic  iritis  ;  and  stiU 
more  frequently  in  choroiditis,  unattended  by  iritis.  I  cannot  re- 
gard it,  then,  as  at  all  diagnostic  of  syphilitic  iritis.  That  it  is  oc- 
casionally met  with  in  this  disease,  I  have  no  doubt ;  but  I  believe 
it  to  be  a  symptom,  not  so  much  of  an  affection  of  the  iris,  as  of  in- 
flammation of  the  choroid  coat,  and  pressure  on  the  ciliary  or  iridai 
nerves. 

Cysts  of  a  yellowish  colour,  rising  on  the  surface  of  the  iris,  con- 
taining pus,  bursting,  and  evacuating  their  contents  into  the  ante- 
rior chamber,  are  not  peculiar  to  syphilitic  iritis,  and  are  different 
from  the  tubercles  or  condylomata  described  by  Beer,  as  diagnostic 
of  this  disease.  The  latter  are  of  a  reddish-brown  colour,  irregular 
on  their  surface,  growing  frequently  from  the  edge  of  the  pupil,  and 
enlarging  sometimes  to  such  a  size,  as  to  press  the  iris  backwards, 
and  even  to  fill  the  anterior  chamber.  Beer  does  not  mention  that 
these  tubercles  suppurate.  Dr.  Monteath  supposes  that  they  some- 
times form  on  the  posterior  surface  of  the  iris,  pushing  it  forwards, 
and  forcing  a  passage  between  its  fibres,  into  the  anterior  chamber. 
They  occasionally  continue  after  all  the  other  symptoms  have  dis- 
appeared. 

If  syphihtic  iritis  is  neglected,  not  only  is  the  pupil  speedily 
closed,  and  bound  down  to  the  capsule  of  the  lens  by  effused  lymph, 
but  the  iris  is  remarkably  changed  in  its  appearance,  much  more 
so  than  in  any  other  species  of  this  disease.  The  cornea,  also,  be- 
comes hazy,  and  sometimes  dotted  over  with  minute  brown  spots. 
The  anterior  chamber  becomes  less  in  size,  from  the  iris  being 
pushed  forwards,  and  at  length,  from  the  cornea  shrinking  in  diam- 
eter.    The  sclerotica,  choroid,  and  retina,  all  partake  in  the  inflam- 


366 

raation  ;  the  retina  becoming  insensible  to  light,  while  the  choroid 
protrudes,  here  and  there,  of  a  deep  bluish  colour,  through  the  ex- 
tenuated sclerotica.  The  lens  and  vitreous  humour  are  also  disor- 
ganized, being  converted  into  a  pultaceous  mass,  which  may  at  last 
be  observed  forming  whitish  projecting  points  through  the  choroid 
and  sclerotica.  From  such  a  state  of  disease,  it  is  impossible  for  the 
eye  to  recover,  so  as  to  preserve  its  natural  form.  Neither  do  we 
find  that  puncturing  the  eye,  in  such  a  state,  affords  any  relief  to 
the  pain  which  the  patient  suffers  ;  it  is  not  from  any  collection  of 
purulent  fluid  that  the  appearance  above  mentioned  arises,  and 
nothing  is  discharged  on  passing  the  lancet  through  the  tunics.  If 
the  system  is  brought  under  the  action  of  mercury,  the  eye  will, 
under  these  circumstances,  shrink  to  a  small  size  ;  but  if  this  is  not 
done,  or  if  an  insufficient  quantity  of  mercury  be  given,  the  sclero- 
tica may  give  way,  and  a  fungous  excrescence  protrude.  At  last, 
from  the  severity  of  the  pain  in  the  eye  and  head,  the  inefficacy  of 
opiates,  the  fever  and  debility  which  are  induced,  and  the  unseem- 
liness of  the  disorganized  organ,  we  shall  be  obliged  to  remove  it 
with  the  knife. 

The  degrees  of  syphihtic  iritis,  and  its  sequelae,  are  of  course,  very 
various.  In  some  cases,  it  is  attended  by  amaurosis,  and  then  the 
pupil  is  enlarged  beyond  the  medium  size.  Sometimes  the  pupil  is 
dilated  to  twice  its  natural  diameter,  the  centre  remaining  black, 
while  its  edge  is  surrounded  by  condylomata.  In  such  cases, 
though  part  of  the  pupil  is  pretty  clear,  the  patient  sees  little  or  none 
on  account  of  the  insensible  state  of  the  retina  ;  yet,  from  this  state, 
the  eye  may  completely  recovei",  by  appropriate  treatment.  The 
terminations  of  the  disease,  if  not  counteracted  b}^  an  early  employ- 
ment of  mercury,  are  generally  such  as  have  been  described  under 
the  third  degree  :  \\z.  closure  of  the  pupil,  obliteration  of  the  an- 
terior and  posterior  chambers,  and  perhaps  even  general  disorgani- 
zation and  sinking  of  the  eyeball.*  Yer}'  differently  from  what 
happens  in  neglected  rheumatic  iritis,  the  inflammation  in  syphili- 
tic iritis  does  not  wear  itself  out,  and  end  in  simple  loss  of  vision  by 
closure  of  the  pupil ;  but  goes  on  from  one  texture  of  the  eye  to 
another,  till  the  whole  are  involved  in  a  process  of  disorganization, 
which  leaves  scarcely  a  trace  of  natural  structure. 

The  pain  which  attends  syphilitic  iritis  is  very  various  in  severi- 
ty. In  general,  it  is  considerable  both  in  the  eye  and  round  the 
orbit :  and,  like  syphihtic  pains  in  the  bones,  greatly  aggravated 
during  the  night. 

Constitutional  symptoms.  This  disease  is  generally  accom- 
panied by  very  evident  manifestations  of  syphihtic  cachexia.  The 
pulse  is  quick,  the  general  strength  impaired,  the  appetite  lost,  the 
countenance  pale  or  sallow,  and  the  skin  covered,  especially  during 
the  night,  with  a  clammy  perspiration.     The  local  secondary  symp- 

•  See  page  353. 


367 

toms,  with  which  I  have  most  frequently  found  syphilitic  iritis  as- 
sociated, have  been,  pustular  and  scaly  eruptions  on  the  face  and 
over  the  body,  and  next  to  these,  sore  throat.  The  pustules  on  the 
face,  which  I  have  met  with  as  attendants  on  syphilitic  iritis,  have 
frequently  been  large,  hard,  and  seated  so  deeply  in  the  skin,  as 
almost  to  deserve  the  name  of  tubercles.  The  scaly  eruptions  on 
the  face  have  occasionall}'^  presented  an  approach  to  the  areolar  form 
of  lepra.  Over  the  body,  again,  where  the  eruption  has  generally 
been  of  a  more  acute  character,  the  appearance  has  been  that  of 
numerous  circular  elevated  spots,  of  a  brownish-red  colour,  about  the 
size  of  a  split  pea.  ending  in  a  desquamation  of  thin  successive  pel- 
licles of  cuticle.  Some  might  perhaps  be  disposed  to  consider  this 
last  as  a  pseudo-syphilitic  eruption. 

Exciting  Causes.  Although  this  disease  is  unquestionably  an 
effect  of  the  constitution  being  contaminated  by  syphilis,  and  al- 
though it  commences,  in  many  cases,  without  any  known  exciting 
cause,  yet  it  not  unfrequently  happens,  that  like  other  secondary 
symptoms  of  syphilis,  and  especially  sore  throat,  it  arises  from  ex- 
posure to  cold.  Slight  blows  on  the  eye,  and  over-exertion  of  the 
organ,  seem  in  other  instances  to  aid  in  bringing  on  this  disease ; 
which  therefore  may  be  regarded,  at  least  in  many  cases,  as  an 
effect  of  certain  external  causes  operating  on  a  constitution  imbued 
with  a  morbid  poison. 

Relapses.  Even  when  syphilitic  iritis  terminates  in  the  most  fa- 
vourable manner,  the  eye,  for  a  long  time  afterwards,  is  peculiarly 
sensible  to  the  influence  of  cold  and  moisture.  On  every  exposure 
to  these,  the  sclerotic  circle  of  inflammation  may  be  observed  to  re- 
turn, the  hght  is  felt  to  be  disagreeable,  and  the  eye  discharges  a 
super-abundant  quantity  of  tears.  For  the  same  reason,  the  forma- 
tion of  an  artificial  pupil,  when  this  is  required  from  the  effects  of 
previous  syphilitic  iritis,  is  generally  followed  by  such  a  degree  of 
renewed  inflammation,  as  to  frustrate  the  attempt  to  restore  vision. 

Treatment.  1.  Blood-letting  is  rarely  necessary  in  syphilitic 
iritis,  and  by  most  authors,  appears  to  be  altogether  discarded. 
Depletion  of  any  kind  is,  no  doubt,  insufficient  to  cure  this  disease, 
which,  besides,  is,  in  most  cases,  unattended  by  that  degree  and 
kind  of  constitutional  irritation  which  demands  the  use  of  the  lan- 
cet. Still,  the  local  symptoms,  and  especially  the  circum-orbital 
pain,  may  be  greatly  reheved  by  the  application  of  leeches  round 
the  eye,  preceded  in  robust  individuals,  by  venesection.  Dr.  Mon- 
teath's  testimony  on  this  point,  is  valuable.  "  Judging  from  my 
own  experience,"  says  he,  "  I  differ  decidedly  from  those  who  put 
their  whole  faith  in  mercury  in  the  cure  of  this  species,  to  the  ex- 
clusion of  the  other  remedies,  such  as  bleeding,  blistering,  &c.  In 
my  own  practice,  I  have  seen  the  disease  running  on  with  rapid 
strides  to  dangerous  hypopion,  notwithstanding  the  full  action  of 
mercury,  and  its  further  progress  at  once  arrested  by  a  full  bleeding 
from  the  arm,  and  a  bhster  on  the  hind-head." 


368 

2'.  Opiate  frictions  round  the  orbit  are  carefully  to  be  employed 
about  an  hour  before  the  nightly  attack  of  pain  is  expected  ;  after 
which,  the  eye  is  to  be  covered  with  a  fold  of  linen,  warmed  at  the 
fire.  Should  the  pain  threaten  to  come  on  about  midnight,  as  it  is 
very  apt  to  do,  or  at  any  other  time  during  the  day  or  night,  the 
opiate  friction  ought  to  be  repeated.  Laudanum,  an  infusion  of 
extract  of  belladonna  in  laudanum,  a  mixture  of  laudanum  with 
tincture  of  cantharides,  moistened  opium,  or  opiate  mercurial  oint- 
ment, will  be  selected  for  this  purpose,  according  to  the  circum- 
stances of  the  case,  and  the  fancy  of  the  practitioner. 

3.  Nauseants,  sudorifics,  diuretics^  ■purgatives,  and  counter- 
irritatio?i  hy  blisters,  have  each  their  use  in  syphilitic  iritis,  but 
are  of  greatly  inferior  importance  to  the  remedy  next  to  be  mentioned. 

4.  Mercury.  Upon  this  medicine  we  place  our  chief  reliance 
for  arresting  syphilitic  inflammation  of  the  iris,  and  removing  the 
morbid  changes  which  may  have  already  been  produced  in  that 
membrane,  and  in  the  pupil.  It  is  not  an  alterative  course  of 
mercury,  however,  which  inust  be  depended  on.  The  constitution 
must  be  thoroughly  mercuriaUzed,  and  the  mouth  made  distinctly 
sore.  The  combination  of  calomel  with  opium,  is  the  best  form 
for  exhibiting  mercury  in  this  disease.  A  pill,  containing  two 
grains  of  the  former,  with  from  half  a  grain  to  a  grain  of  the  latter, 
may  be  given  morning,  noon,  and  night,  till  the  gums  begin  to  be 
affected  ;  after  which,  two  pills  daily  may  be  contined  for  some 
time ;  and  when  the  mercurialization  is  more  advanced,  one  at 
bedtime  only.  This  is  the  plan  to  be  followed  in  severe  cases, 
where  it  is  important  instantly  to  arrest  the  progress  of  the  disease,  to 
prevent  deposition  of  lymph  into  the  pupil,  or  procure  its  absorption, 
if  already  effused.  In  milder  cases,  we  may  trust  to  a  pill  morning 
and  evening  from  the  beginning. 

Other  forms  of  mercury  have  been  employed  in  the  cure  of  this 
disease,  especially  inunction  round  the  eye,  and  corrosive  sublimate 
taken  internally.  But  neither  of  these  can  be  relied  on  when  the 
symptoms  are  urgent,  and  in  all  circumstances  they  are  greatly 
inferior  to  calomel  and  opium.  The  soothing  and  dirigent  effects 
of  the  opium  are  of  no  small  importance. 

Mercuiy,  in  one  form  or  other,  will  require  to  be  continued  for  a 
considerable  length  of  time,  that  not  only  the  iritis  may  be  arrested, 
and  its  effects  removed,  as  far  as  this  is  practicable,  but  that  the 
constitutional  syphilis  also  may  be  completely  cured.  A  removal 
of  the  iritis  must  not  be  depended  on  as  a  proof  of  the  constitution 
being  freed  of  the  syphilitic  virus ;  while,  on  the  other  hand,  a 
removal  of  the  constitutional  disease,  in  many  cases,  is  or  appears 
to  be  effected,  although  there  remains  much  to  be  done,  and  that 
chiefly  by  the  operation  of  mercury,  before  the  eye  is  freed  from 
the  iritis  and  its  consequences. 

5.  Turpentine  has  been  recommended  by  Mr.  Hugh  Car- 
michael  of  Dublin,  in  syphilitic  iritis,  and  other  deep-seated  inflam- 


369 

mations  of  the  eye.  The  cases  which  he  has  related  in  his  in- 
teresting pamphlet,  afford,  I  think,  indubitable  evidence  that  this 
medicine  has  occasionally  removed  that  species  of  iritis  which  is 
considered  as  syphilitic ;  and  even  after  lymph  has  been  effused 
into  the  pupil,  and  condylomata  risen  on  the  surface  of  the  iris, 
has  restored  these  parts  to  their  perfectly  healthy  state.  It  was 
from  the  acknowledged  influence  of  turpentine  in  peritonitis,  and 
the  analogy  in  point  of  morbid  effects  between  inflammation  of  the 
peritoneum  and  that  of  the  iris,  in  both  cases  a  serous  membrane 
being  engaged,  and  in  both,  adhesions  being  produced  between 
surfaces  intended  to  be  free,  that  Mr.  C.  was  led  to  make  use  of 
turpentine  in  iritis.  The  results  were  such  as  to  confirm  the  idea 
he  had  formed.  As  it  is  in  syphilitic  cases  chiefly,  that  he  has 
found  turpentine  useful,  he  is  well  aware  of  the  objection  likely  to 
be  started  by  some,  that  this  medicine  has  never  been  known  to 
possess  any  anti  syphihtic  virtues.  To  this,  he  might  have  ef- 
fectively replied,  by  an  appeal  to  the  non-mercurial  treatment  of 
syphilis,  and  to  the  overpowering  testimony  of  the  facts  which  he 
himself  has  recorded.  He  seems  at  first  disposed,  however,  rather 
to  chime  in  with  the  scepticism  of  Mr.  Travers,  who  is  at  a  loss  to 
determine  whether  what  is  generally  considered  as  syphilitic  iritis, 
is  actually  a  venereal  inflammation,  or  a  symptom  which  merely 
resembles  syphilis,  or  a  disease  ingrafted  on  the  syphilitic,  or  an 
effect  produced  by  the  poison  of  mercury.  But  in  a  more  advanced 
part  of  his  inquiry,  Mr.  C.  declares  in  favour  of  the  doctrine,  that 
mercury  operates  in  the  favourable  manner  in  which  it  is  univer- 
sally acknowledged  to  do  in  syphilitic  iritis,  not  so  much  by  means 
of  any  peculiar  anti-syphilitic  property  which  it  possesses,  as  in 
consequence  of  its  power  to  excite  the  action  of  the  absorbents ; 
and  this  same  sorbefacient  power  he  claims  for  the  oil  of  turpentine. 
This  claim  is  abundantly  vindicated  by  the  cases  which  Mr.  C.  has 
related  ;  and  not  only  so,  but  he  has  also  demonstrated  that  this 
medicine  possesses  a  controlling  power  over  the  inflammatory  pro- 
cess, upon  which  the  effusion  of  lymph,  in  syphilitic  iritis,  depends. 
Although  Mr.  Carmichael  has  the  merit  of  having  brought  for- 
ward a  new  medicine  in  syphilitic  iritis,  of  unquestionable  utility, 
he  is  by  no  means  bUnd  to  the  virtues  of  other  remedies.  He  ac- 
knowledges, that  the  same  antiphlogistic  and  sorbefacient  effects 
which  he  has  derived  from  turpentine,  may  be  produced  in  a  more 
decided  manner,  by  mercury ;  while  he  very  properly  urges,  that 
the  rapidity  with  which  turpentine  pervades  the  body,  and  conse- 
quently brings  disease  under  its  influence,  together  with  the  absence 
of  fever  attending  its  operation  on  the  constitution,  must  render  its 
use  a  matter  of  interest  and  utility,  though  the  same  effects  might 
be  accomplished  by  other  means,  and  even  in  a  more  decided 
manner.  Cases  of  syphilitic  iritis  occasionally  occur,  where,  from 
a  variety  of  circumstances,  the  administration  of  mercury  is,  for 
the  time,  altogether  inadmissible,  or  at  least,  extremely  hazardous. 
47 


370 

How  fortunate  then  will  it  be,  if  an  efficient  substitute  for  mercury 
be  found  in  the  medicine  proposed  by  Mr.  Carmichael ! 

The  dose  of  oil  of  turpentine  is  a  drachm  thrice  a-day.  Its  dis- 
agreeable flavour,  and  nauseating  effects,  may  be  obviated  by  giv- 
ing it  in  the  form  of  emulsion.  If  it  induces  strangury,  lint-seed 
tea  and  camphor  julep  may  be  administered,  or  its  use  suspended 
for  a  time.  The  tendency  to  heartburn,  which  it  sometimes  causes, 
may  be  prevented  by  an  addition  of  ten  or  fifteen  grains  of  car- 
bonate of  soda  to  the  eight  ounce  emulsion,  containing  an  ounce 
of  turpentine. 

When  the  local  inflammation  is  high,  and  acute  pain  is  present 
in  the  eye  and  side  of  the  head,  abstraction  of  blood  ought  by  no 
means  to  be  neglected,  notwithstanding  the  statement  of  Mr.  C. 
that  he  has  frequently,  even  when  these  symptoms  were  urgent, 
relied  solely  on  the  turpentine  mixtm'e,  and  reaped  from  it  the 
most  decided  and  expeditious  relief.  The  condition  of  the  bowels 
will  also  require  attention  ;  the  beneficial  effects  of  the  turpentine 
appearing  to  be  suspended  when  constipation  is  present,  and  again 
called  forth  when  this  is  removed.  Perfect  rest,  too,  if  not  abso- 
lutely necessary,  will  be  found  highly  conducive  to  the  complete  pro- 
duction of  the  salutary  effects  of  the  turpentine.  Mr.  C.  states, 
that  in  a  few  patients,  who,  from  their  particular  situations  in  hfe, 
were  obhged  to  continue  in  active  employment,  the  same  satisfac- 
tory results  did  not  follow  its  exhibition,  nor  was  its  influence  fully 
established,  until  this  was  attended  to. 

In  some  of  the  cases  given  by  Mr.  C.  sedatives  were  employed 
ong    with   turpentine ;    such    as    opium,  henbane,    and   cicuta. 
These  may  be  exhibited,  both  internally  and  externally  ;  and  of 
course,  the  application  of  belladonna  ought  not  to  be  omitted. 

Mr.  C.  states,  that  the  administration  of  turpentine  has  very  sel- 
dom failed  in  effecting  a  perfect  cure  of  syphilitic  iritis,  and  that  an 
amendment  has  generally  been  quite  perceptible  the  day  after  it 
was  commenced.  The  average  period  of  cure  seems  in  his  hands 
to  have  been  about  eleven  days. 

6.  Belladonna  is  to  be  smeared  liberally  on  the  eyebrow  and 
forehead,  every  night  at  bedtime.  This  remedy  ought  to  be  con- 
tinued regularly  for  months,  unless  the  pupil  has  completely  re- 
gained its  natural  freedom  and  mobility. 


SECTION    XIX. ^PSEUDO-SYPHILITIC    IRITIS. 

It  is  generally  admitted  that  there  are  various  diseases,  either 
communicated  by  impure  venereal  intercourse,  or  arising  in  the 
system  without  any  communication  of  that  sort,  which  present  a 
series  of  morbid  phenomena,  milder  and  more  rapid  in  general, 
but  still  in  many  respects,  similar  to  those  of  syphilis.  Till  a  more 
accurate  description  of  the  diseases  in  question  be  obtained,  we 
may  be  allowed  to  speak  of  them  as  syphiloid  or  pseudo-syphilitic. 


371 

The  pustular  eruption  spoken  of  by  Bateman,  under  the  name 
«of  ecthyma  cachecticuTii-,  appears  to  be  one  of  the  disorders  apt  to 
be  confounded  with  true  syphilis  ;  and  there  is  no  doubt  that  it 
occasionally  affects  the  iris,  in  a  manner  closely  resembling  the  iri- 
tis we  have  just  been  considering. 

This  disease  occurs,  Dr.  Bateman  tells  us,  in  connexion  with  a 
state  of  cachexia,  apparently  indicative  of  the  operation  of  a  morbid 
poison.  It  much  resembles  some  of  the  secondary  symptoms  of 
syphilis,  and  is  often  treated  as  syphihtic,  although  there  can  be 
no  doubt  that  it  originates  frequently,  if  not  always,  from  derange- 
ment of  the  general  health,  independent  of  any  thing  like  infection. 

It  generally  commences  with  a  febrile  paroxysm,  which  is  some- 
times considerable.  In  the  course  of  two  or  three  days,  numerous 
scattered  pustules  appear,  with  a  hard  inflamed  base,  on  the  breast 
and  extremities  ;  and  these  are  multiplied,  day  after  day,  by  a  suc- 
cession of  similar  pustules,  which  continue  to  rise  and  decline  for 
several  weeks,  until  the  skin  is  thickly  studded  with  the  eruption, 
under  various  phases.  For,  as  the  successive  pustules  go  through 
their  stages  of  inflammation,  suppuration,  scabbing,  and  desqua- 
mation, at  similar  periods  after  their  rise,  they  are  necessarily  seen 
under  all  these  conditions  at  the  same  time  ;  the  rising  pustules 
exhibiting  a  bright  red  hue  at  the  base,  which  changes  to  a  purple 
or  chocolate  tinge  as  the  inflammation  declines,  and  the  little  lami- 
nated scabs  form  upon  their  tops.  When  these  fall  off,  a  dark 
stain  is  left  upon  the  site  of  the  pustules.  The  eruption  is  some- 
times confined  to  the  extremities,  but  it  frequently  extends  also 
over  the  trunk,  face,  and  scalp. 

The  febrile  symptoms  are  diminished,  but  not  removed,  on  the 
appearance  of  the  eruption  ;  for  a  constant  hectic  continues  during 
the  progress  of  the  disease.  It  is  accompanied  by  great  langour, 
and  much  depression,  both  of  the  spirits  and  muscular  strength  ;  by 
headach,  and  pains  of  the  limbs  ;  and  by  restlessness  and  impaired 
digestion,  with  irregularity  of  the  bowels.  There  is  commonly 
some  degree  of  conjunctivitis,  and  the  fauces  are  the  seat  of  slow  in- 
flammation, accompanied  by  superficial  ulcerations. 

This  disease  is  stated  by  Bateman  to  continue  from  two  to  four 
months,  in  the  course  of  which  time,  by  the  aid  of  vegetable  tonics, 
cinchona,  sarsapariila,  serpentarin,  <fcc.  with  antimonials,  and  the 
warm  bath,  the  constitution  gradually  throws  off  the  morbid  condi- 
tion which  gives  rise  to  it.  He  adds  that  the  administration  of 
mercury  is  neither  necessary'  to  its  cure,  nor  appears  to  accelerate 
recovery.* 

Dr.  Monteath  tells  us  that  the  resemblance  of  the  iritis  produced 
by  this  eruption  to  that  which  is  the  consequence  of  syphilis,  is  so 
striking,  that  for  several  years  of  his  practice  he  invariably  treated 
the  cases  he  met  with,  and  successfully,  by  the  free  use  of  mercury, 

*  Practical  Synopsis  of  Cutaneous  Diseases,  page  187.     London,  1819. 


372 

believing  them  to  be  syphilitic.  "  The  small  circle  of  the  iris,  and 
the  border  of  the  pupil,"  adds  he,  "  are  often  studded  with  the  small 
reddish-yellow  papulae  or  pustules,  so  characteristic  of  the  venereal 
iritis.  It  was  in  consequence  of  several  such  cases  applying  to  me 
with  the  disease  evidently  declining,  and  the  pupil  clearing,  after 
two  or  three  weeks'  continuance,  without  the  patient  having  taken 
one  grain  of  mercury,  and  sometimes  almost  without  any  treat- 
ment that  could  have  been  useful,  that  I  first  saw  my  error,  and  felt 
satisfied  that  these  cases  were  not  syphilitic."  * 

Notwithstanding  the  possibiUty  of  this  iritis  being  cured  without 
mercury,  and  the  fact  that  it  is  occasionally  aggravated  t  by  an  at- 
tempt to  mercurialize  the  system,  still  an  alterative  course  of  this 
medicine  is  to  be  omitted,  neither  in  this  nor  in  any  of  the  other 
pseudo-syphilitic  varieties  of  iritis.  They  will  in  general  yield  to 
such  a  course,  aided  by  sarsaparilla,  local  bleeding,  blisters  behind 
the  ears,  the  application  of  belladonna  to  the  eyebrow,  a  mild  diet, 
quietude  of  the  general  frame  and  of  the  inflamed  organ.  Turpen- 
tine, as  recommended  by  Mr.  Carraichael  for  syphilitic  iritis,  is  wor- 
thy of  a  trial  in  the  pseudo-syphilitic.  Among  the  pseudo-syphili- 
tic varieties  of  iritis,  I  may  include  that  which  sometimes  follows 
gonorrhoea. 


SECTION    XX. SCROFULOUS    IRITIS. 

Notwithstanding  the  great  frequency  of  scrofulous  aflfections  of 
the  external  parts  of  the  organ  of  vision,  the  iris  is  rarely  the  seat 
oi  primary  scrofulous  inflammation,  although  a  secondary  scrofu- 
lous iritis  is  by  no  means  uncommon.  We  call  it  secondary^  not 
only  because  in  the  cases  alluded  to,  inflammation  of  the  cornea  is 
the  usual  precursor  of  any  affection  of  the  iris,  but  because  the  iritis 
appears  to  arise  more  in  consequence  of  the  continuance  of  cornei- 
tis,  and  the  spread  of  inflammation  from  one  texture  of  the  eye  to 
another,  than  from  any  new  external  or  internal  cause  operating 
on  the  iris  itself.t  Cold,  however,  affecting  a  scrofulous  subject, 
occasionally  brings  on  a  mixed  or  compound  ophthalmia,  partly 
phlyctenular,  partly  iritic ;  or  at  least,  we  meet  with  instances  in 
which  inflammation  of  the  latter  sort  so  quickly  supervenes  to  the 
former,  that  we  may  regard  them  as  affording  examples  of  primary 
scrofulous  iritis.  Such  cases  I  have  met  with  repeatedly  ;  they  are 
by  no  means  so  frequent  as  the  secondary  scrofulous  iritis  atten- 
dant on  corneitis. 

The  following  case,  quoted  by  Dr.  Monteath  from  the  journals 
of  the  Eye  Infirmary,  affords  a  good  illustration  of  what  I  am  dis- 
posed to  call  primary  scrofulous  iritis. 

♦  Glasgow  Medical  Journal,  Vol.  ii.  p.  138.    Glasgow,  1829. 
t  See  a  case  which  occurred  in  the  practice  of  Mr.  Arnott,  related  in  the  (Quarterly 
Journal  of  Foreign  Medicine  and  Surgery,  Vol.  i.  p.  78.    London,  1819. 
t   See  page  m 


373 

Robert  Fleininster,  aged  16,  applied  on  the  5th  August,  1827, 
with  sclerotitis  and  iritis  of  the  left  eye,  which  had  resisted  remedies 
for  a  month.  Six  leeches  were  applied  to  the  temple,  and  he  was 
put  on  two  grains  of  calomel  with  a  quarter  of  a  grain  of  opium, 
morning  and  evening.  In  eight  days  the  inflammation  was  gone, 
and  the  sight  restored  nearly  to  its  natural  state.  On  the  17th  he 
was  dismissed  cured.  Iritis  being  of  rare  occurrence  in  children, 
Dr.  M.  suspected  this  case,  and  pointed  it  out  as  probably  strumous. 
What  occurred  in  the  other  eye,  proved  the  suspicion  to  be  just ; 
for  on  the  24th  he  was  admitted  for  an  attack  of  distinct  external 
strumous  inflammation  of  the  other  eye,  with  pustules  and  an  ulcer 
at  the  border  of  the  cornea.  The  solution  of  nitras  argenti  was 
had  recourse  to,  two  leeches  were  applied  to  the  temple,  and  a  blis- 
ter behind  the  ear,  and  he  was  directed  to  bathe  the  eye  with  a  very 
weak  solution  of  corrosive  sublimate. 

On  the  27th,  he  was  no  better,  and  the  colour  of  the  iris  was 
observed  to  be  changed.  It  was  now  evident  that  the  inflammation 
would  become  iritic,  as  it  had  done  in  the  other  eye.  Four  leeches 
were,  therefore,  applied  to  the  temple,  and  the  pills  of  calomel  and 
opium  commenced  again,  as  before.  On  the  31st  the  inflammation 
appeared  still  advancing,  and  the  iris  becoming  more  affected.  The 
leeches  were  repeated,  and  the  calomel  with  opium  continued.  In 
five  days  after  this,  the  mouth  was  sore,  and  the  inflammation 
nearly  gone.  The  mercury  was  now  omitted  ;  and,  on  the  1 4th, 
he  was  dismissed  perfectly  cured. 

This,  then,  was  a  well-marked  case  of  acute,  and  I  think  we  may 
say  ^primary.,  strumous  iritis.  The  readiness  with  which  it  yielded 
to  appropriate  treatment  is  worthy  of  attention.  Had  the  treatment 
been  improper  or  inefficient,  the  boy  must  have  lost  his  sight. 
Whenever  iritis  is  observed  in  a  very  young  person,  struma  may 
be  suspected  as  the  predisposing  cause  ;  the  other  species  of  iritic 
inflammation  being  rare  in  childhood.  The  treatment  must  be 
such  as  was  employed  in  the  case  just  quoted  ;  that  is  to  say,  in 
addition  to  the  treatment  demanded  lay  strumous  ophthalmia, 
calomel  and  opium  must  be  given  till  the  mouth  is  affected. 
The  pupil  also  ought  to  be  kept  under  the  influence  of  bella- 
donna. 

The  same  plan  must  be  followed  in  cases  of  secondary  iritis 
accompanying  strumous  cofneitis.  I  have  already  hinted,  in  pages 
348  and  353,  at  the  difficulty  of  discerning,  through  the  inflamed 
cornea,  the  exact  state  of  the  iris  and  pupil.  Several  of  the  symp- 
toms, also,  which  attend  strumous  corneitis  and  iritis,  are  of  an 
equivocal  sort,  for  the  zonular  inflammation  of  the  sclerotica,  the 
supra-orbital  or  circum-orbital  pain,  and  the  impaired  state  of  vision, 
are  common  to  iritis  and  corneitis  in  their  separate  state,  as  well  as 
when  they  exist  together.  When  the  opacity  of  the  cornea  is  not 
very  great,  we  shall  be  able,  however,  to  discern  at  least  the  size, 
and  degree  of  mobility,  possessed  by  the  pupil.     If  that  aperture  is 


374 

contracted,  irregular,  and  motionless,  there  can  be  no  question  but 
that  severe  iritis  is  or  has  been  present.  But  in  many  cases,  by 
concentrating  the  hght  upon  the  cornea  through  a  double  convex 
lens,  we  may  observe  even  the  discolouration  of  the  iris,  and  the 
whitish  cobweb  of  effused  lymph  occupying  the  pupil. 

Neglected  cases  of  this  compound  ophthalmia  are  frequently  met 
with,  in  which,  from  the  low  state  of  the  inflammation  and  slight- 
ness  of  the  pain,  the  disease  has  been  allowed  to  go  on  for  years, 
till  at  last  vision  has  become  almost  extinct.  A  remarkable  cir- 
cumstance in  such  neglected  cases  is  the  great  degree  of  softness 
or  bogginess  which  both  the  cornea  and  the  sclerotica  present,  on 
being  pressed  with  the  finger.  This  I  regard  as  a  very  unfavour- 
able sign  ;  denoting  in  fact  a  disorganization  of  the  vitreous  hu- 
mour, always  attended  by  a  considerable  degree  of  amaurosis. 

Whenever  iritis  is  observed  to  co-exist  with  strumous  cornei- 
tis,  an  attempt  must  be  made,  by  mercury  and  belladonna,  to  coun- 
teract the  narrowed  state  of  the  pupil,  and  the  effusion  of  lymph 
from  the  iris.  From  the  pecuhar  constitution  of  the  subjects  of 
this  iritis,  as  well  as  the  chronic  nature  of  the  disease,  the  adminis- 
tration of  mercury  must  be  conducted  with  more  than  ordinary 
caution  and  patience  ;  the  gums  will  in  the  first  instance  require  to 
to  be  decidedly  affected,  after  which  repeated  gentle  courses  of  the 
medicine  will  be  necessary,  while  the  system  must  be  supported 
during  the  intervals,  by  nourishing  diet  and  the  use  of  tonics. 
Turpentine  has  not  been  tried  in  scrofulous  iritis. 

We  must  beware  of  employing  stimulants,  with  the  view  of 
clearing  the  cornea,  so  long  as  there  is  any  suspicion  of  active 
inflammation  k«eing  present  in  the  iris ;  else  we  may  readily  bring 
on  such  a  degree  of  irritation,  as  shall  end  in  annihilation  of  the 
anterior  chamber,  and  of  course  in  irreparable  loss  of  sight. 


SECTION    XXI. ARTHRITIC    IRITIS. 

The  disease  described  by  the  German  ophthalmologists  under 
the  name  of  arthritic  iritis,  is  known  by  many  remarkable  charac- 
ters, and  is  unquestionably  connected  with  a  peculiar  state  of  the 
constitution.  I  have  often  been  led  to  doubt  whether  it  be  in  reali- 
ty a  purely  gouty  inflammation  :  and  even  now,  I  am  not  alto- 
gether decided  as  to  this  point.  In  this  country,  however,  we  do 
not  very  frequently  meet  with  those  affections  of  the  eyes  which 
the  Germans  have  designated  as  arthritic,  and  to  decide  on  a  ques- 
tion of  this  sort,  except  after  ample  experience  and  careful  observa- 
tion, would  be  absurd.  Dr.  Monteath,  who  had  paid  great  atten- 
tion to  the  diagnosis  of  eye-diseases,  appears  to  have  been  fully  con- 
vinced of  the  justness  of  the  views  entertained  in  Germany  regard- 
ing arthrictic  diseases  of  this  organ.  There  is  one  thing  to  be 
considered,  that  in  this  country,  gout  is  a  disease  very  rarely  met 


375 

with  in  any  form,  except  among  the  opulent  and  hixurious  ;  while 
in  the  wine  countries  of  the  continent  of  Europe,  and  especially  in 
Austria,  where  wine  is  the  beverage  of  all  ranks,  gout,  and  especial- 
ly what  we  term  irregular  gout,  is  common  even  among  the  poorest 
of  the  people. 

Arthritic  iritis  originates  in  two  ways.  In  one  case,  it  is  the 
primary  and  sole  affection  of  the  eye  ;  in  another,  an  individual 
of  arthritic  constitution  being  affected  with  some  common  ophthal- 
mia, as  rheumatic,  catarrho-rheumatic,  or  traumatic,  this  degen- 
erates into  the  arthritic.  The  same  thing  occasionally  happens  in 
regard  to  syphilitic  iritis.  The  arthritic  originates  more  frequently  in 
this  way  than  in  the  other. 

Symptoms.  The  general  symptoms  of  iritis  are  present  in  the 
arthritic  species  ;  namely,  zonular  sclerotitis,  discolouration  of  the 
iris,  turbid ness  of  the  pupil,  with  changes  in  its  shape,  size,  and 
mobihty,  impaired  vision,  and  pain  in  and  around  the  eye.  These 
symptoms,  however,  are  modified  in  such  a  manner  as  to  afford 
ground  for  a  ready  diagnosis. 

1.  Redness.  The  conjunctiva  is  loaded  with  enlarged  vessels 
as  well  as  the  sclerotica.  The  redness  is  of  a  purplish  hue  ;  and 
what  is  strongly  insisted  on  as  a  diagnostic  mark  of  arthritic  iritis, 
the  inflamed  vessels  are  stopped  abruptly  before  reaching  the  edge 
of  the  cornea  by  a  narrow  ring  of  a  bluish-white  colour.  This 
ring  sometimes  does  not  occur,  particularly  at  the  commencement 
of  the  disease,  all  round  the  cornea,  but  only  at  its  temporal  and 
nasal  sides.  The  visible  arteries  of  the  eye,  derived  from  the  recti 
muscles,  show  from  the  very  first  a  strong  disposition  to  become 
varicose,  and  at  length  are  so  strikingly  dilated  as  to  form  another 
characteristic  symptom  of  arthritic  iritis.  The  sclerotica  loses  its 
natural  appearance,  and  becomes  of  a  dirty  greyish-violet  colour. 
Most  of  these  appearances,  and  especially  the  livid  colour  and  vari- 
cose dilatation  of  the  blood  vessels,  are  regarded  as  indicative  of  a 
great  tendency  to  atony,  which  may  account  for  this  variety  of 
iritis  being  much  less  amenable  to  antiphlogistic  treatment  than  the 
others. 

2.  Changes  in  the  iris  and  pupil.  Beer  has  described  these 
as  varying  in  two  different  habits  of  body.  In  those  who  are  of 
a  meagre  and  irritable  habit,  and  tense  fibre,  the  pupil  contracts, 
is  filled  with  effused  lymph,  and  becomes  adherent  to  the  capsule, 
as  is  generally  the  case  in  the  other  species  of  iritis.  In  such 
cases,  the  only  characteristic  symptom,  besides  the  white  ring  round 
the  cornea,  is  a  varicose  state  of  the  blood  vessels  of  the  iris,  so 
that  after  the  disease  has  fully  developed  itself,  they  may  be  dis- 
cerned ramifying  on  the  surface  of  that  membrane,  or  forming  a 
vascular  wreath  within  the  verge  of  the  contracted  pupil.  Before 
it  arrives  at  this  stage,  the  inflammation  is  always  attended  with 
general  fever.  If  the  eye  is  left  to  itself,  it  does  not  suppurate,  but 
its  contents  begin  to  be  absorbed,  and  at  last  its  volume  is  extremely 
diminished. 


376 

In  those,  again,  who  are  of  a  gross  habit  of  body,  poj^sess  little 
sensibility,  and  have  a  lax  fibre,  the  iris  instead  of  expanding,  con- 
tracts remarkably,  a  sign  of  attending  amaurosis,  and  at  the  same 
time  loses  its  motion  and  natural  black  colour.  The  pupil  is  not 
always  dilated  uniformly  along  its  whole  circumference ;  not  un- 
frequently  the  iris  contiacts  more  towards  the  temporal  and  nasal 
sides  of  the  eye,  so  that  the  pupil  assumes  an  oval  shape  ;  indeed^ 
the  iris  sometimes  becomes  so  narrow^  on  the  two  sides  mentioned, 
especially  on  the  temporal,  as  almost  to  disappear.  Along  with 
these  changes,  there  is  no  effusion  of  lymph,  nor  any  abscess  on 
the  surface  of  the  iris.  Behind  the  enlarged  pupil,  there  is  per- 
ceived the  greyish-green  reflection,  characteristic  of  glaucoma,  a 
state  of  the  eye  depending  on  absorption  of  the  pigmentum  nigrum, 
with  dissolution  of  the  vitreous  Jiuinour,  and  occasionally  accom- 
panied by  discolouration  of  the  lens.  After  a  time,  the  lens  is  plain- 
ly seen  to  have  lost  its  transparenc)',  and  to  have  assumed  an 
opaque  sea-green  colour  ;  it  swells  considerably,  and  projects  through 
the  pupil,  into  the  anterior  chamber.  The  iris,  lying  upon  the 
enlarged  lens,  seems  much  altered  from  its  natural  texture ;  it 
looks  soft,  and  as  if  it  had  undergone  a  degree  of  maceration.  The 
varicose  state  of  the  vessels  of  the  conjunctiva  increases,  while  those 
of  the  choroid,  becoming  similarly  affected,  form  bluish  knots, 
which  shine  tbrough  the  sclerotica.  The  anterior  part  of  this  tunic 
being  extenuated  by  the  pressure  of  the  morbid  parts  within,  a 
dark  ring  shines  through  it,  exactly  occupying  the  situation  of  the 
corpus  ciliare.  Vision  is  by  this  time  totally  gone.  The  inflamma- 
tory symptoms  now  begin  to  decrease,  and  absorption  of  the  contents 
of  the  eyeball  follows  as  in  the  former  instance.  In  either  case, 
if  both  eyes  are  not  simultaneously  attacked,  the  same  process  at- 
tacks the  one  eye  after  the  other,  and  follows  a  similar  course,  till 
both  are  destroyed. 

3.  Pain.  It  sometimes  happens  that  before  any  other  signs  of 
arthritic  ophthalmia  make  their  appearance,  the  patient  is  troubled 
with  peculiar  tingling  sensations  about  the  eye,  and  a  feeling  of 
creeping  over  the  skin  of  the  face.  The  eye  and  the  orbit  soon 
become  the  seat  of  racking  pain,  extending  to  the  temple,  and 
shooting  down  into  the  jaws.  During  the  progress  of  the  changes 
of  structure  above  detailed,  the  attacks  of  pain  are  regular  and  very 
severe,  greatly  aggravated  in  general  towards  midnight,  but  in  som& 
cases  suffering  little  abatement  at  any  period  of  the  twenty-four 
hours.  The  patient  is  warned  of  their  approach,  by  a  stinging 
sensation  all  round  the  eye,  followed  by  an  increased  flow  of  tears ; 
after  which,  the  pain  sets  in.  and  becomes,  in  many  instances,  so 
extremely  violent,  that  the  patient  is  forced  to  writhe  under  it,  and 
to  utter  the  most  piercing  cries  of  distress. 

4.  Secretion  from  eyelids.  The  epiphora  which  attends  arth- 
ritic inflammation  of  the  iris,  leads  to  frequent  opening  and  shutting" 
of  the  eyelids,  by  means  of  which  there  is  forced  out  from  betweeii. 


377 

them,  a  peculiar  white  frothy  matter,  wFiich  Beer  regarded  as  diag- 
nostic of  arthritic  ophthahnia,  and  which  is  easily  distinguished 
from  any  of  the  ordinary  secretions  of  the  conjunctiva  or  Meibo- 
mian follicles.  On  examining  this  foam  or  froth,  it  appears  to  con- 
sist of  extremely  minute  globules  of  watery  fluid. 

Constitutional  symptoms.  The  subjects  of  arthritic  iritis  will 
be  found,  I  believe,  to  have  suffered  much  more  frequently  from 
the  symptoms  of  irregular  than  of  regular  gout.  They  will  pre- 
sent, in  general,  that  combination  of  plethora  with  debility,  which 
is  so  characteristic  of  the  gouty  constitution,  and  will  be  found  to 
have  long  been  the  victims  of  a  variety  of  affections  of  the  stomach, 
such  as  nausea,  vomiting,  flatulency,  acid  eructations,  and  pains  in 
the  epigastrium.  Irregular  bowels,  pains  and  cramps  in  different 
parts  of  the  trunk  and  extremities,  headaches,  giddiness,  an  erup- 
tion of  suppurating  tubercles  on  the  face,  wiih  lowness  of  spirits, 
will  also  be  found  to  have  prevailed  more  or  less,  in  those  who  are 
attacked  by  this  species  of  ophthalmia.  One  of  the  worst  cases  I 
have  seen,  was  in  a  person  who,  without  being  a  drunkard,  had 
for  many  years  laboured  under  a  great  degree  of  gutta  rosacea. 
An  erroneous  plan  of  diet,  and  especially  an  indulgence  in  alcoholic 
fluids  and  tobacco,  will  in  general  be  found  to  have  been  followed 
by  those  who  suffer  from  this  iritis. 

Prognosis.  This  is  more  unfavourable  than  in  any  of  the  other 
species  of  iritis.  A  first  attack  may  continue  for  many  months,  and 
though  at  last  the  symptoms  may  yield,  and  a  tolerable  degree  of 
vision  be  saved,  a  renewal  of  the  disease  is  always  to  be  dreaded, 
owing  to  the  extreme  difficulty,  not  to  say  impossibility,  of  removing 
the  arthritic  disposition.  Besides  its  obstinacy,  there  is  another  cir- 
cumstance connected  with  arthritic  inflammation  of  the  eye,  which 
renders  the  prognosis  peculiarly  unfavourable,  namely,  the  strong 
tendency  which  the  disease  has  to  affect  the  choroid,  retina,  and 
humours,  so  that  though  the  attack  may  for  several  successive  times 
be  iritic,  the  rest  of  the  eyeball  becomes  at  length  implicated  and 
destroyed. 

Cure.  The  three  most  important  indications  are,  1st,  To  re- 
move the  inflammation,  2d,  To  subdue  pain,  and,  3d,  To  prevent 
relapses. 

1st,  Though  inflammation  be,  as  Dr.  Monteath  has  well  re- 
marked, the  proximate  cause  of  all  the  evils  in  this  species  of  iritis, 
as  in  the  traumatic  or  any  other,  yet,  as  it  is  of  an  unsound  and 
peculiar  nature,  and  dependent  on  a  constitutional  cause,  it  cannot 
be  eradicated  by  the  vigorous  use  of  mere  antiphlogistic  means. 
General  bleeding  is  seldom  advisable  in  arthritic  iritis,  and  may 
even  aggravate  the  subsequent  course  of  the  disease.  Even  local 
bleeding,  by  cupping  and  leeches,  must  be  cautiously  employed. 
Except  in  sanguineous  and  plethoric  habits,  and  sometimes  even 
in  them,  blood-letting  in  this  disease  will  often  disappoint  our  hopes, 
especially  in  elderly  people,  and  instead  of  alleviating  the  symptoms, 
48 


378 

rather  increase  the  feverish  irritation  and  restlessness.  If  we  ven- 
ture on  general  bleeding,  the  quantity  drawn  at  once  should  not 
exceed  ten  or  twelve  ounces.  If  necessary,  this  quantity  may  again 
be  taken  away  in  twelve  or  twenty-four  hours.  In  most  cases, 
however,  the  application  of  leeches  to  the  temple,  forehead,  and 
eyelids,  besides  its  local  effect,  produces  all  the  benefit  which  is  to 
be  derived  from  the  evacuation  of  blood. 

The  bowels  ought  to  be  freely  opened  by  one  or  more  smart  doses 
of  calomel  and  colocynth.  followed  after  some  hours  by  salts  and 
senna.  If  the  tongue  still  continues  foul  and  the  mouth  bitter,  a 
common  dose  of  ipecacuan  and  tartar  emetic  may  be  of  much  ser- 
vice. After  this,  the  bowels  are  to  be  kept  open  by  laxatives,  and 
the  skin  excited  to  moisture  by  some  mild  diaphoretic. 

The  free  use  of  mercury  is  as  imsuitable  in  arthritic  iritis  as 
profuse  blood-letting.  An  alterative  course  of  this  medicine,  how- 
ever, will  be  of  much  service,  and  may  be  continued  for  weeks  or 
months,  along  with  other  suitable  remedies,  so  as  to  change  the 
vitiated  habits  cf  the  digestive  organs.  To  arrest  the  m.orbid  ac- 
tion of  the  capillaries,  and  check  the  effusion  of  lymph,  in  this  iritis, 
by  the  t^ndden  introduction  of  mercury,  as  in  the  other  species  of 
this  disease,  has  been  found  impracticable.  Whetlier  any  better 
effects  are  to  be  derived  from  turpentine,  as  recommended  by  Mr. 
Carmichael,  future  experience  must  determine. 

I  have  sometimes  derived  very  striking  benefit  from  the  use  of 
the  precipitated  carbonate  of  iron,  in  arthritic  ophthalmia,  after 
depletion  and  mercury  had  been  employed  without  relief  Sulphate 
of  quina  is  another  remedy  which  might  be  tried  with  some  hope 
of  success. 

Counter-irritation,  by  blistering  and  otherwise,  is  of  great  ser- 
vice. Beer  particularly  recommends  the  bringing  out  of  an  arti- 
ficial  eruption  by  means  of  tartar  emetic  ointment. 

Dry  warmth,  applied  by  means  of  several  folds  of  old  hnen, 
heated  at  the  fire,  hung  over  the  eye,  and  renewed  frequently,  is 
the  only  direct  application  to  the  inflamed  organ  which  can  at  all 
times  be  used  with  impunity.  It  promotes  an  increase  of  the  insen- 
sible perspiration,  and  in  this  way  is  of  much  use.  Cold  applica- 
tions uniformly  do  harm  ;  and  even  hot  fomentations,  with  poppy 
decoction  and  the  like,  are  not  always  safe,  especially  if  the  parts 
are  left  wet  and  exposed  after  their  apphcation. 

2d,  To  moderate  and  remove  as  quickly  as  possible  the  periodi- 
cal fits  of  pain,  is  a  matter  of  great  importance.  For  this  purpose. 
Beer  recommends  simply  opium,  moistened  to  the  consistence  of  a 
liniment,  to  be  rubbed  in,  round  the  orbit.  Mercurial  ointment 
with  opium  and  extract  of  belladonna,  or  volatile  hniment  with 
laudanum,  may  be  used  for  the  same  purpose.  The  friction  is  to 
be  performed  when  the  evening  paroxysm  is  expected  to  recur,  and 
repeated  during  the  night  if  the  pain  is  not  prevented,  or  should 
threaten  to  return  at  any  period  of  the  day  or  night.     The  internal 


379 

use  of  opiurn  ought  if  possible  to  be  avoided,  on  account  of  the 
disordered  state  of  the  digestive  organs.  Should  the  pain,  how- 
ever, become  very  urgent,  it  ought  not  to  be  withheld.  Consider- 
able relief  may  also  be  obtained  from  the  internal  use  of  stramoni- 
um, hyosciamus,  belladonna,  colchicum,  and  prussic  acid,  none  of 
which  have  the  same  bad  effects  on  the  hver  and  bowels  as  opium. 
I  have  found  a  vinous  solution  of  murias  hydrargyri  with  bella- 
donna, a  convenient  form  for  exhibiting  the  latter  medicine  as  a 
sedative,  and  the  former  as  an  alterative,  in  this^  disease.  The 
causes  which  seem  to  produce  accessions  of  pain  must  be  careful- 
ly avoided  ;  as,  agitation  of  mind,  sudden  changes  of  temperature, 
&c. 

3d,  Relapses  are  to  be  warded  off,  partly  by  constitutional,  part- 
ly by  local  means. 

The  constitutional  preventive  means  are  partly  medicinal,  but 
chiefly  dietetical.  The  general  health  must  be  confirmed  as  much 
as  possible,  by  proper  management  of  the  digestive  organs,  the 
kidneys,  and  the  skin.  A  temperate  diet,  careful  regulation  of 
the  bowels  by  gentle  aperients,  and  a  free  action  of  the  kidneys, 
promoted  by  the  use  of  magnesia  or  soda  water,  or  of  some  mild, 
aperient,  and  diuretic  mineral  water,  will  be  of  much  benefit. 
Daily  tepid  sponging  of  the  body,  followed  by  dry  friction,  will  be 
of  service  by  promoting  an  abundant  secretion  from  the  skin. 
The  patient  should  breathe  pure  country  air,  and,  carefully  avoid- 
ing either  to  overheat  or  cool  himself  too  quickly,  should  engage 
in  regular  and  continued  exercise  of  various  kinds.  If  he  has  long 
been  accustomed  to  wine,  he  may  be  allowed  a  small  quantity  of 
spirits  and  water. 

After  an  attack  of  gouty  inflammation  in  the  foot,  we  see  the 
pans  continue  long  tumid,  weak,  and  morbidly  sensible,  while  the 
most  trifling  accident,  internal  or  external,  is  apt  to  produce  a  re- 
lapse. The  same  is  observed  in  regard  to  the  eye,  only  that  in 
this  organ  we  have  the  advantage  of  directly  witnessing  the  ex- 
ceedingly relaxed,  varicose,  and  livid  state  of  the  blood  vessels  ;  an 
indication  of  how  much  is  wanting  to  restore  the  aflfected  parts  to 
their  natural  tone.  Even  after  an  acute  attack  of  arthritic  iritis  is 
subdued,  some  counter-irritating  means  ought  to  be  continued, 
such  as  a  seton  in  the  neck ;  and  recourse  should  be  had  to  the  use 
of  local  applications  of  a  tonic  kind.  As  a  means  of  this  sort,  the 
Germans  are  in  the  way  of  using  small  bags  of  dried  aromatic 
herbs,  suspended  over  the  eye.  The  bags  are  made  of  old  hnen, 
and  are  quilted,  so  as  to  keep  the  herbs  equally  spread  out.  The 
aroma,  constantly  emanating  from  the  herbs,  imparts  a  permanent, 
pleasant,  and  useful  stimulus  to  the  debilitated  blood  vessels  and 
nerves.  The  best  herbs  for  this  purpose,  are  bruised  chamomile 
flowers,  sage,  rosemary,  marjoram,  and  the  like,  with  or  without 
the  addition  of  a  little  powdered  camphor.  If  the  exhaled  aroma 
reproduces  redness  of  the  eye  or  aversion  to  light,  this  will  indicate 


380 

that  tfle  proper  time  for  the  use  of  local  stimuU  has  not  yet  arrived, 
and  that  they  must  be  postponed.  Friction  round  the  orbit  once  or 
twice  daily  with  alcohol,  tinctura  aromatica  ammoniata,  or  the 
like,  is  another  local  preventive  measure  which  is  found  of  use. 
Even  stimulants  to  the  eye,  as  vinum  opii  and  red  precipitate  salve, 
beginning  these  preparations  in  a  dilute  state,  and  gradually  aug- 
menting their  strength,  are  found  to  abate  the  morbid  sensibility 
of  the  eye,  and  thus  render  it  less  apt  to  suffer  from  the  ordinary 
external  as  well  as  internal  causes  which  produce  inflammation. 
It  must  not  be  forgotten,  however,  that  remedies  of  this  kind,  if 
used  before  the  inflammation  is  completely  subdued,  will,  as  in 
every  other  species  of  iritis,  produce  the  very  worst  effects. 


SECTION    XXII.^-CHOROIDITIS. 

As  the  choroid  coat  is  completely  hid  from  view,  and  exercises 
but  a  subsidiary  function,  it  is  not  to  be  wondered  at,  that  while 
inflammation  of  every  other  part  of  the  eye,  conjunctiva,  sclerotica, 
cornea,  iris,  lens,  and  retina,  has  been  accurately  discriminated, 
inflammation  of  the  choroid  has  hitherto  scarcely  attracted  atten- 
tion. In  an  early  stage,  choroiditis  is  one  of  the  least  striking  of 
the  ophthalmiae ;  when  far  advanced,  the  signs  of  disorganization 
which  attend  it,  are  more  remarkable  than  those  of  vascular  action  ; 
and  while  the  effects  are  too  serious  not  to  have  attracted  attention, 
the  cause  of  these  effects,  and  the  seat  of  the  original  disease,  have 
in  general  been  hid  in  obscurity,  or  passed  over  without  notice. 

I  have  already  had  occasion  to  mention,  that  iritis  is  occasionally 
attended  by  inflammation  of  the  choroid.  Were  we  to  adopt  the 
common  notion,  that  the  iris  is  a  continuation  of  that  membrane, 
we  might  be  led  to  conclude,  that  choroiditis  and  iritis  should  always 
go  together.  Perhaps,  in  some  degree,  this  may  still  be  the  case. 
At  the  same  time,  from  the  arteries  which  nourish  these  two  parts 
being  quite  distinct  in  their  course  and  distribution,  the  idea  of 
a  separate  iritis,  and  a  separate  choroiditis,  is  a  priori  rendered 
probable. 

For  some  time,  the  separate  existence  of  choroiditis  was  with  me 
rather  a  matter  of  speculation,  and  a  conclusion  from  analogy, 
than  a  fact  ascertained  by  observation.  I  am  now  convinced,  how- 
ever, that  the  choroid  is  sometimes  the  seat,  almost  quite  inde- 
pendently, of  inflammation ;  that  in  certain  cases  of  ophthalmia, 
it  is  the  focus  of  the  disease,  and  that  the  neighbouring  parts  may 
be  as  little  affected  when  that  is  the  case,  as  the  sclerotica  is  in  iritis, 
or  the  iris  in  sclerotitis.  That  it  is  of  importance  to  distinguish 
the  disease  which  I  am  now  about  to  describe,  will  appear  very 
evident,  when  we  consider  its  dangerous  nature.  Its  symptoms, 
as  we  shall  immediately  see,  are  very  different  from  those  of  any 
other  ophthalmia ;  and  although  ultimately  the  whole  eye  may 


381 

be  involved  by  inflammation  commencing  in  the  choroid,  yet 
choroiditis,  in  the  early  stage,  exists  without  any  signs  of  disease 
in  the  iris,  and  without  any  other  effects  upon  the  sclerotica  and 
retina,  than  those  which  must  necessarily  arise  from  the  pressure 
of  an  inflamed  and  swoln  membrane,  placed  in  contiguity  with 
other  membranes,  more  or  less  susceptible  of  suffering  from  that 
pressure.  I  consider  ciroroiditis,  therefore,  as  completely  a  primary 
and  distinct  disease. 

Symptoms.  1,  Discolouration  of  the  white  of  the  eye.  From 
the  pressure  outwards  of  the  inflamed  and  tumefied  choroid,  the 
exterior  tunics  of  the  eye  become  extenuated,  so  that  the  choroid 
shows  its  dark  colour  through  the  sclerotica,  which  therefore  ap- 
pears blue  or  purplish.  This  is  one  of  the  most  remarkable  symp- 
toms of  choroiditis,  and  takes  place  in  many  cases  at  a  very  early 
period  of  the  disease.  The  degree  of  the  discolouration  is  different, 
according  to  the  severity  and  duration  of  the  attack,  being  some- 
times merely  perceptible  on  comparing  the  diseased  with  the  healthy 
eye,  or  the  diseased  side  of  the  eye  with  the  healthy  side,  while  in 
other  instances,  it  amounts  to  a  deep  blue. 

2.  Tum,our.  After  continuing  for  a  time  discoloured  merely,  the 
part  affected  protrudes.  This  commonly  takes  place  on  one  side 
only  of  the  eyeball,  generally  near  the  cornea,  as  if  the  corpus 
ciliare  was  the  seat  of  the  disease  ]  and  more  frequently  above,  or 
to  the  temporal  side  of  the  cornea,  than  below,  or  to  its  nasal  side. 
The  tumour  may  enlarge  to  the  size  and  prominence  of  half  a 
filbert  or  m.ore.  It  is  then  generally  of  a  deep  blue  colour,  with 
varicose  vessels  running  over  it,  and  has  been  described  under  the 
name  of  sclerotic  staphyloma.  Several  such  tumours  may  sur- 
round the  cornea. 

The  front  of  the  eye,  however,  is  not  the  only  seat  of  choroid 
staphyloma,  as  it  might  be  called  with  more  propriety  than  sclero- 
tic, considering  the  actual  origin  of  the  protrusion.  Scarpa  tells 
us  that  he  had  never  met  with  any  tumour  or  elevation  of  the 
sclerotica  on  its  anterior  surface,  resembling  a  staphyloma ;  but 
that  he  had  twice  happened  to  meet,  in  the  dead  body,  with  staphy- 
loma of  the  posterior  hemisphere  of  the  sclerotica.  The  first  time 
was  in  the  eye  of  a  woman  of  forty  years  of  age.  The  eye  was 
of  an  oval  figure,  and  upon  the  whole,  more  voluminous  than  the 
sound  eye  on  the  other  side.  On  the  posterior  hemisphere  of  the 
diseased  eye,  and  to  the  external  or  temporal  side  of  the  entrance 
of  the  optic  nerve,  the  sclerotica  was  elevated  in  the  form  of  an  ob- 
long tumour,  like  a  small  nut.  As  the  cornea  was  sound  and  pel- 
lucid, and  the  humours  still  preserved  their  natural  transparency, 
on  looking  through  the  pupil,  there  appeared  towards  the  bottom 
of  the  eye,  an  unusual  brightness,  produced  by  the  light  penetrat- 
ing that  part  of  the  sclerotica,  which  had  become  thin  and  tran- 
sparent where  it  was  occupied  by  the  staphyloma.  When  the  eye 
was  opened,  the  vitreous  humour  was  found  entirely  disorganized, 


382 

and  converted  into  limpid  water,  and  the  crystalline  lens  some- 
what yellowish,  but  not  opaque.  When  the  posterior  hemisphere 
of  the  eye  was  immersed  in  spirit  of  wine,  with  a  few  drops  of  ni- 
trous acid  added  to  it,  in  order  to  give  the  retina  consistence  and 
opacity.it  was  distinctly  perceived  that  there  was  a  deficiency  of 
the  nervous  expansion  of  the  retina  within  the  cavity  of  the  staphy- 
loma ;  that  the  choroid  was  very  thin  at  this  part,  deprived  of  its 
natural  colour,  and  of  its  usual  vascular  network  ;  and  that  the 
sclerotica,  particularly  at  the  apex  of  the  staphyloma,  was  so  thin 
as  scarcely  to  equal  tlie  thickness  of  writing  paper.  The  woman 
from  whom  this  eye  w"as  taken,  had  lost  the  faculty  of  seeing  on 
that  side  some  years  before,  during  an  obstinate  ophthalmia,  at- 
tended with  most  severe,  and  almost  iiabitual  pains  in  the  head. 

Scarpa  had  an  opportunity  of  making  similar  observations  on  an 
eye  met  with  accideutall}^  by  Dr.  Monteggia  of  Milan.  It  was 
taken  from  a  woman,  thirty-five  years  of  age,  was  of  an  oval 
figure,  and  longer  than  its  fellow.  The  staphyloma  was  situated 
exactly  as  in  the  former  instance.  The  vitreous  humour  was  dis- 
solved ;  the  crystalline  capsule  was  distended  by  a  thin  whitish 
fluid ;  the  lens  yellowish,  and  less  than  natural ;  the  retina  defi- 
cient within  the  staphyloma ;  the  choroid  and  sclerotica,  forming 
the  (umour,  thinned,  so  as  to  transmit  the  hght.  Nothing  positive 
could  be  ascertained  regarding  this  woman's  sight.* 

3.  Effusion  heiv:een  choroid  and  retina.  That  the  vessels  of 
the  choroid  are  greatly  enlarged  in  this  disease,  does  not  admit  of 
a  doubt.  I  remember  having  seen  in  the  hands  of  Professor  Beer, 
a  preparation  in  which  the  varices  of  an  inflamed  choroid  were  as 
large  as  small  peas.  At  the  same  lime,  the  distention  which  the 
choroid  and  sclerotica  suffer  in  this  disease,  is  not  owing  entirely  to 
thickening  of  the  former  coat,  or  to  varicose  distention  of  its  blood 
vessels,  but  is  often  connected  with  an  effusion  of  watery  fluid  be- 
tween the  choroid  and  retina.  This  I  have  frequendy  had  occa- 
sion to  evacuate  with  the  needle.  If  this  is  not  done,  it  accumu- 
lates to  such  a  degree  as  to  press  the  retina  before  it,  and  having 
at  last  produced,  by  means  of  its  continued  pressure,  an  absorption 
of  the  vitreous  humour,  it  gathers  the  retina  into  a  cord,  which 
stretching  from  the  entrance  of  the  optic  nerve  to  behind  the  lens, 
is  seen  through  the  pupil,  and  looks  like  a  deep-seated  cataract,  or 
like  the  advancing  tumour  in  medullary  fungus  of  the  optic  nerve. 
A  beautiful  specimen  of  this  state  of  the  retina,  I  owe  to  the  kind- 
ness of  Mr.  Norris,  of  the  Royal  Infirmar}'. 

4.  Redness.  The  arteries  which  are  visible  on  the  surface  of 
the  sclerotica  in  the  state  of  health,  are  much  enlarged  in  cases  of 
choroiditis,  and  ramify  over  the  distended  portion  of  the  sclerotica. 
Not  unfrequently  we  observe  a  patch  of  redness  near  the  edge  of 
the  cornea^  fed   by  one  or  more  of  these  arteries,  greatly  dilated, 

*  Trattato  delle  principali  Malattie  degli  Occbi.    Vol,  ii.  p.  146.    Pavia,  J 816. 


383 

Sometimes  the  redness  is  confined  to  the  upper  part  of  the  eyeball. 
There  is  scarcely  ever  any  general  redness,  or  much  iullammation 
of  the  conjunctiva.  It  is  either  sclerotic,  or  consists  in  an  enlarge- 
ment of  the  visible  arteries  derived  from  the  recti  muscles. 

5.  Displacement  of  the  pupil.  The  iris  is  not  affected  with 
inflammation  in  choroiditis  ;  but  the  pupil,  in  almost  every  case 
which  1  have  witnessed,  has  undergone  a  remarkable  change  of 
place.  The  iris  is  always  narrowed  towards  the  portion  of  the 
choroid  which  is  affected,  and  in  many  instances,  the  pupil  is  ob- 
served to  have  moved  so  much  out  of  its  natural  situation,  as  to  be 
almost  directly  behind  the  edge  of  the  cornea.  Upwards,  and  up- 
wards and  outwards,  are  the  directions  in  which  the  pupil  is  most 
frequently  observed  to  become  displaced.  It  occasionally  continues 
small  and  movable,  in  other  cases  it  is  immovable,  but  not  dilated  : 
in  very  severe  cases  it  is  greatly  enlarged,  the  iris  having  entirely 
disappeared  at  that  part  of  its  circumference  towards  which  the 
displacement  of  the  pupil  has  happened. 

The  remarkable  displacement  of  the  pupil  which  attends  choroi- 
ditis is  owing  probably  to  some  affection  of  one  or  more  of  the  cilia- 
ry or  iridal  nerves,  which  running  forward  between  the  sclerotica 
and  choroid,  pass  through  the  annulus  ganglitbrmis,  and  ultimately 
reach  the  iris.  This  symptom  has  been  remarked  by  Beer  as  an 
attendant  on  syphilitic  iritis.  That  it  is  not  a  constant  attendant 
is  well  known.  I  have  seen  it  in  other  varieties  of  iritis.  It  has 
never  been  attributed  to  any  affection  of  the  choroid,  nor  has  ai,y 
explanation  of  its  cause  been  offered. 

The  pupil  does  not  return  to  its  place,  even  although  the  choroid- 
itis is  subdued. 

6.  Opacify  of  the  cornea  is  of  course  not  a  necessary,  although 
a  frequent  attendant  on  choroiditis.  It  is  generally  the  edge  of  the 
cornea  nearest  to  the  portion  of  affected  choroid  which  becomes 
opaque,  so  as  to  resemble  part  of  a  broad  arcus  senilis,  the  rest  of  the 
cornea  remaining  perfect ly  clear.  In  other  cases,  there  are  pretty 
extensive  but  very  irregular  spots  of  whiteness,  more  the  effect  ap- 
parently of  interrupted  nutrition  than  inflammation.  In  some  se- 
vere and  long-continued  cases  of  choroiditis,  the  cornea  becomes  al- 
most altogether  opaque,  and  partaking  in  the  staphylomatous  de- 
generation of  the  neighbouring  sclerotica,  even  undergoes  a  degree 
of  dilatation,  so  as  to  become  considerably  broader  and  more  promi- 
nent than  it  is  in  the  natural  state. 

From  this  affection  of  the  cornea  alone,  independent  of  the  inte- 
rior changes  of  the  eye,  the  patient's  vision  may  be  almost  or  alto- 
gether lost. 

7.  Exophthalmos  and  exophthalmia.  In  consequence  of 
choroiditis,  the  eye  may  enlarge,  and  even  protrube  from  the  orbit 
to  a  very  considerable  degree,  without  much  inflammation  of  the 
sclerotica  and  conjunctiva,  these  tunics  being  merely  thinned  by  the 
pressure  of  the  distended  choroid.     After  a  time,  however,  the  eye 


384 

in  this  state  of  exophthalmos,  is  apt  to  suffer  from  external  inflam- 
mation, in  consequence  of  being  but  imperfectly  protected  by  the 
lids,  or  it  may  be,  in  consequence  of  cold  or  mechanical  injury. 
When  the  inflammation^  thus  excited,  runs  to  a  great  height,  the 
conjunctiva  becomes  chemosed,  puriforrn  fluid  is  deposited  behind 
the  cornea,  or  between  its  lamellse,  the  eye  bursts,  continues  to  swell 
and  protrude  still  more,  assumes  a  fungous  appearance,  bleeds  pro- 
fusely, and  being  productive  of  great  pain  and  deformity,  evidently 
requires  to  be  extirpated. 

8.  Intolerance  of  light  and  epiphora,  generally  attend  this  dis- 
ease in  a  considerable  degree. 

9.  Pain.  This  varies  much  irk  different  individuals.  When 
there  is  yet  no  protrusion,  the  pain  is  moderate ;  when  the  scleroti- 
ca is  much  pressed  and  distended,  and  especially  when  this  takes 
place  suddenly,  and  is  attended  with  considerable  increase  of  red- 
ness, the  pain  in  the  eye  becomes  severe,  and  sometimes  furious, 
Hemicrania  is  also  present,  affecting  principally  the  top  of  the  head,, 
the  high  part  of  the  temple,  and  the  cheek.  It  is  not  strictly  cir- 
cum-orbital,  nor  is  it  strikingly  nocturnal. 

10.  Vision  is  variously  affected  in  cases  of  choroiditis.  In  some, 
the  very  first  symptom  complained  of,  is  dimness  of  sight.  Hemi- 
opia,  all  objects  to  one  or  other  side  of  a  perpendicular  line,  or  above 
or  below  a  horizontal  line,  appearing  dim,  all  objects  appearing 
confusedly,  and  as  if  double,  even  when  viewed  with  one  eye,  are 
symptoms  which  not  unfrequently  distress  the  pEitient  long  before 
any  redness  or  blueness  of  the  eye  is  visible..  If  the  disease  goes 
on,  we  sometimes  find  that  total  blindness  ensues,  even  when  the 
choroid  appears  but  partially  affected  ;  while  in  other  cases  the 
whole  choroid  is  evidently  affected,  the  whole  eyeball  enlarged 
and  discoloured,  and  yet  a  considerable  degree  of  vision  is  retained. 

Constitutional  symptoms.  1.  The  subjects  of  this  disease  are 
adults.  I  have  never  seen  it  in  children.  Those  of  strumous  con- 
stitution are  more  subject  to  it  than  others. 

2.  Various  degrees  of  febrile  excitement  attend  choroiditis.  In 
the  early  stage,  before  distention  brings  on  acute  pain,  the  pulse  is  not 
affected ;  after  the  patient  has  suffered  much,  a  cachectic  state  is 
apt  to  follow,  with  quick  pulse,  pale  or  sallow  complexion,  excessive 
nervous  irritability,  and  great  general  weakness. 

3,  The  digestive  organs  are  frequently  much  *deranged,  even 
from  the  very  first.  Want  of  appetite^  frequent  acidky  of  stomach, 
costiveness,  flatulence,  and  foul  tongue,  attend  the  disease  in  many 
instances. 

Remote  and  exciting  causes.  I  have  been  led  to  ascribe  the 
commencement  of  inflammation  of  the  choroid  to  such  causes  as^ 
the  following. 

1.  Want  of  exercise  ;  too  much  confinement  within  doors. 

2.  Derangement  of  the  stomach  and  bowels. 

3.  Over-use  of  the  eyes,  iri  reading,  sewing,  rainiature-paintingy 
and  other  minute  works. 


385 

4.  Exposure  to  too  much  heat  and  light,  and  especially  to  the 
glare  of  hot  fires,  and  to  sudden  changes  from  heat  to  cold. 

5.  Blows  on  the  eye. 

Prognosis.  Recovery  is  always  slow.  If  the  disease  has  gone 
to  any  considerable  length,  it  is  scarcely  ever  completely  removed. 
The  vestiges  of  it  are  in  general  permanent,  even  after  it  lias  been 
completely  checked  in  its  progress.  In  many  cases,  we  may  leckon 
ourselves  fortunate,  if  we  arrest  this  disease.  Yet  it  sometimes 
happens  that  the  cure  proceeds  to  a  degree  beyond  our  expectation. 
I  lately  attended  a  gentleman  who  many  years  before  had  almost 
entirely  lost  the  sight  of  the  left  eye  from  this  disease.  The  right 
was  now  attacked.  Both  pupils  were  greatly  displaced ;  the  visible 
arteries  of  the  right  eye  were  much  dilated,  and  the  sclerotica  at 
different  places  considerably  extenuated  ;  the  left  eye  was  enlarged, 
of  a  pretty  deep  blue  colour,  and  a  great  part  of  the  cornea  opaque. 
By  blood-letting,  counter-irritation,  and  other  remedies,  the  disease 
was  arrested  in  the  right  eye,  and  very  unexpectedly  the  left  eye 
recovered  to  such  a  degree,  that  he  was  again  able  to  read  with  it 
an  ordinary  type. 

Treatment.  1.  Blood-letting.  Profuse  and  repeated  blood- 
letting does  more  good  in  the  early  stage  of  choroiditis,  than  all 
other  remedies  put  together.  Yet  we  might  perhaps  not  be  tempted 
to  bleed  sufficiently  at  this  period  of  the  disease,  from  the  circum- 
stance that  in  many  instances,  there  are  no  external  signs  of  in- 
tense inflammation,  and  the  patient  does  not  suffer  any  acute  pain. 
The  practitioner,  therefore,  who  is  not  acquainted  with  the  nature 
and  symptoms  of  this  ophthalmia,  might  be  apt  to  trifle  away  time 
in  the  application  of  a  few  leeches,  when  he  should  be  opening  the 
temporal  artery,  and  removing  a  large  quantity  of  blood.  I  have 
known  the  blueness  and  evident  distension  of  the  sclerotica,  which, 
notwithstanding  leeching  and  other  remedies,  had  continued  una- 
bated for  many  weeks,  disappear  suddenly  and  completely,  after 
the  loss  of  twenty  or  thirty  ounces  of  blood  from  the  temple. 
Bleeding  from  the  jugular  vein,  or  from  the  arm,  is  also  highly 
useful.  Twenty-four  or  more  leeches  round  the  eye,  every  second 
day,  I  have  seen  attended  by  the  best  effects.  In  chronic  cases, 
we  must  not  neglect  the  frequent  and  hberal  application  of  leeches. 

2.  Purgatives  are  of  essential  service.  The  disordered  state  of 
the  biliary  and  other  digestive  organs,  indicates  the  use  of  calomel 
as  a  cholagogue,  followed  by  salts  and  senna,  or  some  other  brisk 
purgative.  Such  remedies  are  to  be  repeated  frequently,  during 
the  course  of  the  treatment. 

3.  Mercury.  We  are  naturally  led  to  advise  mercury  in  choroid- 
itis, from  observing  its  happy  effects  in  iritis.  But  on  the  whole, 
I  must  confess,  that  in  the  former  disease,  I  have  not  witnessed 
any  remarkable  benefit,  either  from  making  the  mouth  sore,  or 
from  small  doses  long  continued.  I  have  used  this  medicine  both 
in  friction  to  the  head,  and  in  various  forms  internally ;  but  it  has 

49 


386 

appeared  inert  so  fnr  as  the  choroiditis  is  concerned.  Still,  I  have 
hitherto  continued  to  prescribe  mercury  in  this  disease,  because  the 
cases  which  I  have  treated  are  too  few  to  enable  me  to  decide  com- 
pletely on  this  point,  si ul  because  this  medicine  is  found  to  do  good 
in  all  other  chronic  inflammations  of  I  he  eye. 

4.  Turpentine  I  have  lately  tried  in  one  or  two  cases,  but  am 
unable  as  yet  to  come  to  any  conclusion  regarding  its  effects. 

5.  Iodine.  In  one  case  only  have  I  fully  tried  this  powerful 
sorbefacient,  and  I  am  happy  to  say,  with  an  amount  of  good 
effects  altogether  unlocked  for.  An  eye  which  1  had  many  times 
punctured,  and  had  fairly  made  up  my  mind  to  extirpate,  has 
shrank  considerably  under  the  use  of  the  tincture  of  iodine,  while 
the  sclerotica  has  assumed  much  mere  of  its  natural  whiteness. 

6.  Tonics.  After  due  depletion,  1  have  seen  much  benefit  ac- 
crue from  the  precipitated  carbonate  of  iron,  and  the  sulphate  of 
quina.     They  may  be  given  separate!}',  or  together. 

7.  Counter-irritation  is  decidedly  useful.  A  tartar  emetic  erup- 
tion between  the  shoulders  is  perhaps  the  most  effectual. 

8.  Paracentesis  oculi.  Puncturing  the  sclerotica  and  choroid, 
so  as  to  evacuate  the  aqueous  fluid  collected  between  the  latter 
tunic  and  the  retina,  is  a  remedy  of  much  importance  in  the  treat- 
ment of  this  disease.  It  is  not  to  be  tried  in  the  acute  stage,  at 
least  I  have  not  dared  to  try  it  exxept  in  the  chronic  stage,  and 
when  there  was  an  evident  tendency  to  stapbyloma  scleroticae. 
The  operation  is  performed  with  a  broad  cataract-needle,  which  is 
to  be  thrust,  not  in  the  direction  of  the  lens,  which  it  might  readily 
wound  and  render  opaque,  but  towards  the  centre  of  the  vitreous 
humour.  The  instrument  need  not  penetrate  deeper  than  the 
eighth  of  an  inch.  A  little  blood  is  usually  discharged  from  the 
divided  portion  of  the  choroid,  mixed  with  aqueous  fluid  of  a  slight- 
ly glutinous  consistence.  The  operation  gives  great  relief  to  the 
feeling  of  distension  or  pressure  in  the  eye,  and  to  the  attendant 
headach.  It  may  be  repeated  every  eight  days,  or  at  longer  in- 
tervals, according  to  the  state  of  the  eye.* 


SECTION  XXIII. RETINITIS.? 

It  is  easy  t-o  understand  that  the  internal  inflammations  of  the 
eye  may  arise  sometimes  in  one  texture,  and  at  other  times  in  an- 
other ;  that  in  one  case  the  blood  vessels  of  the  retina  shall  be  first 
affected,  in  another,  those  of  the  choroid,  in  a  third,  those  of  the  iris. 
The  point  of  origination  will  depend  on  the  natural  constitution  of 
the  organ,  and  the  manner  of  action  of  the  exciting  cause.  Even 
from  biith,   the  eye  varies  much  in  different  individuals,  one  or 

>  See  a  case  of  Staphyloma  Scleroticae  successfully  treated,  by  repeatedly  tapping- 
the  Eye  ;  by  Richard  Martland,  M.D.,  in  the  Edinburgh  Medical  and  Surgical  Jour- 
nal, Vol.  xxiii.  p.  59.     Edin.  1825. 

t  Ophthalmitis  interna  idiopathica  propria  sic  dicta  of  Beer. 


387 

other  texture  appearing  to  be  congenitally  weaker  or  stronger  than 
the  otliers,  so  that  the  same  exciting  cause,  operating  on  a  number 
of  persons,  shall  produce  in  one,  inflammaiio;i  of  the  conjunctiva; 
in  another,  sclerotitis  ;  in  a  third,  iritis;  in  a  fouilh,  inflaniiviiiuon 
of  the  retina.  On  the  other  hand,  the  nature  of  the  cause  ieads  in 
one  case  to  external,  in  another,  to  internal  ophihnhma.  Cold,  ope- 
raiing  on  the  eye,  will  bring  on  inflammation  of  the  conjunctiva  or 
sclerotica,  while  the  sudden  and  direct  reflection  of  a  strong  light 
into  the  eye  will  be  apt  to  produce  an  inflammation  of  which  the 
retina  is  likely  to  be  the  focus.  The  inflammatory  action,  however, 
is  seldom,  if  ever  confined  to  the  part  first  affected.  We  have  al- 
ready seen  how  inflammation,  originating  in  the  iris,  spreads  to  the 
sclerotica,  and  to  the  choroid  ;  and  how  choroiditis  affects  the  tex- 
tm^es  both  within  and  without  the  choroid.  In  the  same  way,  in- 
flammation commencing  in  the  retina  is  likely  to  spread  inwards  to 
the  vitreous  humour,  to  the  capsule  of  the  lens,  and  to  the  lens  it- 
self, all  which  parts  are  fed  by  branches  from  the  central  artery  of 
the  retina ;  and  outwards,  to  the  choroid  and  iris  to  the  sclerotica 
and  cornea,  and  to  the  conjunctiva.  Thus  an  inflammation  of  the 
whole  eyeball  may  arise  from  a  very  limited  point  of  origin. 

Nor  is  this  a  fanciful  picture  of  disease.  Although  a  retinitis, 
ending  in  general  ophthalmitis,  and  arising  from  causes  of  very 
limited  and  transient  action,  is  rare  ;  yet  it  occasionally  occurs,  es- 
pecially after  long  continued  straining  of  the  sight  in  the  examina- 
tion of  very  snjall,  perhaps  microscopical  objects,  under  a  strong 
light,  reflected  into  the  eye,  either  immediately  from  the  object  of 
examination,  or  from  a  speculum. 

In  such  cases,  however,  there  are  commonly  certain  predisposing 
causes,  which  ought  not  to  escape  observation  ;  such  as  plethora  in 
and  near  the  organ  of  vision. 

Unexpected  and  vivid  flashes  of  lightning  sometimes  excite  in- 
flammation of  the  retina,  and  this  disease  has  frequently  been  ex- 
cited by  imprudently  viewing  an  eclipse  of  the  sun.  Prisoners,  who 
have  been  long  confined  to  the  darkness  of  a  dungeon,  have  been 
seized  with  intlamniation  of  the  retina  on  being  brought  suddenly 
forth  into  the  full  glare  of  day.  Travelling  over  a  long  tract  of 
coimtry  covered  with  snow,  has  been  known  to  produce  the  same 
effect.  Saint-Yves  notices  the  case  of  a  man  who  became  blind  in 
consequence  of  going  too  close  to  (he  light  and  heat  of  a  strong  fire, 
in  attempting  to  tie  a  string  to  a  fowl,  turning  on  the  spit ;  and  an- 
other of  a  workman  in  the  mint,  who  lost  his  sight  from  the  bril- 
liant flashing  to  which  he  was  exposed,  while  pouring  metal  into  a 
red-hot  crucible.  Both  of  these  accidents  were  probably  owing  to 
retinitis. 

The  Esquimaux,  who  inhabit  Hudson's  Bay,  are  well  aware  of 
the  loss  of  vision  which  arises  from  exposing  the  eyes  to  the  con- 
stant vie.v  of  a  country  covered  with  snow.  They  make  use  of  a 
kind  of  preservers,  which  they  term  snow  eyes.     These  consist  of 


388 

two  pieces  of  wood  or  ivory,  so  formed  as  to  fit  the  eyes,  which  they 
completely  cover,  and  are  fastened  behind  the  head.  Each  piece 
presents  a  narrow  slit,  through  which  every  thing  is  distinctly  seen. 
This  invention  preserves  them  from  the  snow-blindness,  which  is 
apt  to  be  occasioned  by  the  strong  reflection  of  the  sun's  rays  ;  and 
which,  it  is  probable,  is  the  effect  of  inflammation  excited  in  the 
retina.* 

Blinding  persons  by  producing  retinitis  was,  and  still  is,  in 
some  countries,  a  mode  of  punishment.  The  person  is  compelled 
to  look  steadily  on  a  concave  mirror  of  polished  steel,  held  opposite 
to  the  sun.  This  would  excite  speedy  inflammation  of  the  retina, 
and  certainly  end  in  a  greater  or  less  degree  of  insensibility  to  light. 
Some  such  method  must  be  employed  in  India  at  this  day,  as  many 
of  the  native  princes,  who  have  been  condemned  to  the  loss  of  sight 
by  the  jealousy  of  their  rivals,  but  are  suffered  to  live  in  a  state 
of  captivity,  are  said  to  have  no  appearance,  at  a  little  distance,  of 
being  blind. 

Chronic  cases  of  retinitis  not  unfrequently  present  themselves  to 
our  observation,  under  the  designation  of  weakness  of  sight,  and 
are  characterised  by  a  morbid  sensibility  to  hght  and  slight  obscu- 
rity of  vision,  followed  after  a  lapse  of  time  by  gradual  contraction 
of  the  pupil,  immobility  of  the  iris,  and  amaurosis.  Watchmakers, 
jewellers,  and  those  who  spend  great  part  of  the  day  and  night  in 
reading  and  writing,  are  apt  to  be  affected  in  this  way.  Such 
cases  are  often  injured  by  stimulant  and  tonic  treatment,  while  on 
the  other  hand,  they  are  greatly  benefited  by  leeches  round  the  eye. 

Dr.  Mirault  has  published  a  paper  on  inflammation  of  the  re- 
tina,! in  which  he  describes  under  this  name,  the  common  strumous 
or  phlyctenular  ophthalmia,  maintaining  that  the  excessive  intoler- 
ance of  hght  which  accompanies  this  disease,  can  be  attributed  only 
to  retinitis.  This,  however,  is  a  mistake.  We  see  an  equal  de- 
gree of  intolerance  of  hght  brought  on,  in  an  instant,  by  the  pres- 
ence of  a  particle  of  dust  between  the  eyeball  and  upper  eyelid  ; 
and  there  can  be  no  doubt,  1  think,  that  conjunctivitis,  not  retinitis, 
is  the  cause  of  the  same  symptom  in  strumous  ophthalmia. 

The  following  are  the  symptoms  of  sudden  and  severe  retinitis. 
The  patient  first  complains  of  a  general  feeling  of  pressure  and 
tension  in  the  whole  eyeball.  To  this  there  succeeds  an  obtuse, 
deep-seated,  pulsating  pain,  which  seems  to  inciease  every  moment, 
and  soon  extends  to  the  eyebrow  and  cranium.  The  power  of 
vision  is  already  sensibly  diminished,  and  every  hour  becomes  more 
and  more  feeble.     At  the  same  time,  the  pupil  is  observed  to  have 

*  These  instruments  also  increase  the  powers  of  vision,  so  that  the  Esquimaux  are 
so  accustomed  to  their  use,  that  when  they  are  desirous  of  ^dewing  any  thing  at  a  dis- 
tance, they  mechanically  apply  them  to  their  eyes.  Different  accounts  are  given  of 
the  slit  or  slits  in  these  instruments,  for  some  tell  us  there  is  only  one  in  each  eye-piece, 
and  that  it  is  long  and  narrow,  while  others  say  that  there  are  two,  about  a  quairterof 
an  inch  long.     This  is  probably  regulated  by  the  fancy  of  the  wearer. 

♦  Archives  Generales  de  Medecine.    Tome  xx.  p.  477.    Paris,  1829. 


389 

lost  its  glancing  blackness,  and  to  have  become  much  contracted. 
Without  becoming  angular  or  deviating  from  its  natural  situation, 
it  at  length  completely  closes,  the  iris  having  reached  its  greatest 
possible  degree  of  expansion,  and  seeming  no  longer  to  be  perforated 
b}^  any  central  opening.  Long  before  the  pupil  is  closed,  the  sen- 
sibility of  the  retina  seems  extinct ;  and  yet,  even  when  the  pupil 
is  closed,  and  there  is  no  longer  any  trace  of  perception  of  light 
from  without,  the  patient  experiences  a  troublesome  sensation  of 
fiery  spectra  with  every  oscillation  of  the  internal  blood  vessels  of 
the  eye. 

While  these  changes  are  taking  place,  the  iris  loses  its  natural 
colour,  becoming  greenish  or  reddish  according  to  its  original  hue. 
The  anterior  chamber  is  strikingly  diminished  in  size,  the  iris  hav- 
ing advanced  towards  the  cornea.  By  the  time  that  this  advancing 
of  the  iris  is  first  discerned,  which  is  generally  when  the  pupil  is 
still  of  considerable  size,  the  whole  sclerotica  is  rose-red.  The  con- 
junctiva some  time  after  presents  a  pretty  thick  net-work  of  blood 
vessels,  and  the  cornea  loses  much  of  its  natural  lustre  without  be- 
coming absolutely  opaque.  The  last  mentioned  symptoms  make 
their  appearance  under  severe  inflammatory  sympathetic  fever, 
along  with  insufferable  and  almost  maddening  headach.  Some- 
times it  happens  that  during  this  first  period  of  the  disease,  the  pu- 
pil, though  much  contracted,  does  not  completely  close ;  but  it  is 
cloudy,  and  on  looking  at  it  through  a  magnifying  glass,  or  even 
by  merely  concentrating  the  light  upon  it,  is  seen  to  be  reddish-gray, 
while  the  power  of  vision  is  totally  lost. 

So  severe  are  the  sympathetic  fever  and  headach  which  attend 
retinitis,  that  ii  sometimes  passes  with  medical  men  who  have  not 
studied  the  diseases  of  the  eye,  for  phrenitis  or  brain  fever,  the  char- 
acteristic symptoms  of  this  ophthalmia,  from  which  the  affection  of 
all  the  other  parts  arises,  not  being  sufficiently  prominent  to  arrest 
attention.  The  oculist  generally  finds  retinitis  so  far  advanced  in 
its  progress,  as  to  be  almost  altogether  beyond  control. 

The  pain  of  the  eye  now  becomes  unequal ;  it  is  still  pulsative, 
but  is  now  attended  by  a  feeling  of  cold  and  weight  in  the  part. 
Shiverings  take  place,  and  there  suddenly  appears  a  quantity  of 
pus  at  the  bottom  of  the  anterior  chamber.  This  matter  presents 
a  horizontal  surface  and  is  sometimes  seen  to  change  its  position 
on  the  head  being  moved  from  side  to  side.  It  constantly  increases 
in  quantity,  till  it  not  only  reaches  the  pupil,  but  at  length  fairly 
fills  the  anterior  chamber.  It  may  accumulate  to  such  a  degree, 
especially  in  neglected  cases,  that  the  cornea  projects,  assumes  the 
appearance  of  an  abscess  ready  to  burst,  and  at  last  gives  way  un- 
der insufferable  pain.  The  eye  then  collapses,  and  the  pain  grad- 
ually subsides. 

If  the  pupil  has  not  completely  closed  by  the  end  of  the  first 
stage,  we  see,  just  at  the  moment  when  the  hypopium  begins  to 
form,  fine  whitish  filaments  of  lymph  shooting  from  the  edge  of 


390 

the  pupil  towards  its  centre.  Viewed  through  a  good  lens,  these 
have  the  appearance  of  a  dehcate  cobweb.  After  the  pus  has  cov- 
ered the  pupil,  and  reumined  perhaps  long  unabsorbed,  this  cob- 
web-iike  pseudo-membrane  becomes  whitish-yellow  from  little  par- 
ticles of  the  pus  lodging  in  its  interstices,  and  sometimes  a  single 
piece  of  what  appears  to  be  thickened  purulent  matter,  attached  to 
this  membrane,  projects  through  the  pupil,  intimately  connected 
also  with  the  pupillary  edge  of  the  iris.  But  if  the  pupil  has  closed 
completely  in  the  first  stage,  of  course  nothing  of  this  spurious  cat- 
aract is  observed. 

Prognosis.  The  prognosis  in  retinitis  is  not  unfavourable,  if 
a  proper  method  of  treatment  be  commenced  before  the  pupil  is 
much  contracted,  or  the  power  of  vision  greatly  lessened.  If  vis- 
ion seems  already  extinguished,  the  prognosis  is  extremely  unfa- 
vourable. Beer,  indeed,  had  in  two  cases  seen  vision  return  with 
the  arrest  of  the  inflammatory  symptoms,  but  in  both  a  very  con- 
siderable weakness  of  sight  remained  during  life,  and  the  patients 
could  read  large  print  only  with  much  difficulty,  and  small  print 
not  at  all.  If  the  pupil  be  once  closed,  even  before  the  retina  ap- 
pears to  have  become  insensible,  there  is  no  longer  any  hope  of 
preserving  sight ;  for  even  should  the  pupil  re-open  in  some  degree, 
as  it  occasionally  does  on  the  inflammatory  symptoms  being  ar- 
rested, yet  it  remains  small  and  motionless,  and  the  eye  is  still 
blind.  If  retinitis  be  completely  misunderstood  in  the  commence- 
ment, neglected  or  mistreated,  it  proceeds  rapidly  on  to  a  dangerous 
inflammation  of  the  whole  eyeball. 

In  the  second  stage  the  pi'ognosis  is  always  bad.  For  before 
the  disease  has  advanced  so  far,  vision  is  irretrievably  lost.  All 
that  can  be  done  is  to  endeavour  to  save  the  form  of  the  eye,  by 
limiting  the  suppuration  as  much  as  possible.  If  this  disease  has 
been  misunderstood  at  the  commencement  or  mistreated,  so  that 
it  has  gone  on  to  a  complete  ophthalmitis,  attended  with  chemosis, 
there  is  much  danger  that  in  the  second  stage  not  even  the  form 
of  the  eye  will  be  saved. 

Treatment.  Complete  rest  of  the  eyes  and  of  the  whole  body, 
darkness,  abstinence,  and  active  depletion,  followed  by  the  rapid 
introduction  of  mercury  into  the  system,  are  the  means  to  be  de- 
pended upon  in  the  first  stage  of  retiniiis.  Copious  blood-lettmg 
from  the  arm  is  to  be  immediately  followed  by  a  plentiful  cipoiica- 
tion  of  leeches  round  the  eye.  Should  the  pain  of  the  eye  and  head 
still  continue,  the  jugular  vein  or  temporal  artery  ought  to  be 
opened,  and  a  considerable  quantity  of  blood  abstracted. 

Calomel  with  opium  ought  to  be  given  in  frequent  doses,  till  the 
mouth  is  yffected. 

Belladonna  is  to  be  applied  in  the  usual  way. 

In  the  second  stage,  the  preservation  of  sight  is  out  of  the  ques- 
tion. A  warm  emollient  poultice  is  to  be  laid  over  the  eyelids. 
If  only  a  small  quantity  of  matter  be  present  in  the  anterior  chain- 


391 

ber,  we  must  on  no  account  let  ourselves  be  induced  by  that  to 
open  the  cornea,  for  the  purpose  of  evacuating  it ;  but  trust  to  the 
sorbefacient  effect  of  the  mercury,  assisted  by  blisters  behind  the 
ears  or  on  the  back  of  the  neck.  Beer  recommends  the  eye  in  that 
state  to  be  touched  repeatedly  in  the  course  of  the  day  with  vinuni 
opii,  by  the  careful  use  of  which,  in  combination  with  the  internal 
employment  of  opium  and  sometimes  of  cinchona,  he  had  seen 
collections  of  pus  in  the  anterior  chamber  completely  disappear. 
Should  the  hypopium  increase,  so  that  the  anterior  chamber  is 
filled,  we  cannot  trust  to  its  absorption,  but  must  give  exit  to  the 
matter  by  opening  the  cornea  with  the  extraction  knife.  In  such 
circumstances,  the  natural  appearance  of  the  cornea  and  iris  is 
completely  lost,  the  eyeball  sometimes  remaining  flattened  in  the 
situation  of  the  cornea,  while  in  other  cases  it  becomes  staphyloma- 
tous. 


SECTION  XXIV. AQ.UO-CAPSULITIS. 

By  the  term  aquo-capsulitis  is  meant  inflammation  of  the  car- 
tilaginous membrane,  generally  considered  as  serous,  which  lines 
the  internal  surface  of  the  cornei.  When  this  membrane  is  in- 
flamed, it  becomes  more  or  less  opaque  ;  thers  is  at  the  same  time 
a  rauddiness  in  the  anterior  chamber,  and  occasionally  an  appear- 
ance as  if  the  eyeball  were  unusually  full  and  prominent.  This 
arises  from  an  increase  in  the  quantity  of  the  aqueous  humour, 
the  balance  of  action  being  suspended,  which  naturally  exists  be- 
tween the  exhalents  and  absorbents  of  that  fluid.  In  more  severe 
cases,  coagulable  lymph  is  effiised  from  the  lining  membrane  of  the 
cornea,  and  if  the  iris  be  at  the  same  time  in  an  inflamed  state, 
this  eff'usion  may  become  the  medium  of  adhesion  between  the 
iris  and  the  cornea. 

Besides  the  diffiised  muddiness,  there  are  often  present  in  this 
disease  one  or  more  milk-hke  spots  on  the  internal  surface  of  the 
cornea,  which  even  the  least  experienced  may  readily  distinguish 
from  any  of  the  common  superficial  opacities  of  that  part.  The 
spots  in  question  give  the  cornea  a  mottled  appearance,  and  form 
by  far  the  most  characteristic  mark  of  this  ophthalmia.  Mr. 
Wardrop  has  accurately  described  their  more  opaque  central  points 
as  surrounded  by  a  kind  of  disk,  resembhng  what  is  called  the  eye 
of  a  pebble.  He  seems  to  ascribe  the  whiter  point  in  the  centre 
to  opacity  of  the  substance  of  the  cornea,  and  the  disk  to  that  of 
the  lining  membrane. 

This  mottled  appearance  I  have  seen  very  distinctly  in  two 
cases  ;  and  what  was  very  remarkable,  in  one  of  these,  the  spots 
appeared  and  disappeared  at  different  points  of  the  internal  surface 
of  the  cornea,  even  in  the  space  of  a  few  hours,  so  that  the  patient 
saw  worse  in  the  morning  when  most  of  the  spots  were  observed, 


392 

and  better  towards  the  evening  when  those  at  the  upper  part  of 
the  cornea  had  greatly  diminished.  There  accompanied  this  sin- 
gular case,  a  general  turbid ness  in  the  morning.  The  whole  ap- 
pearance of  the  anterior  chamber,  and  of  the  spots  in  question, 
resembled  very  much  the  effect  which  might  be  supposed  to  be 
produced,  were  a  quantity  of  minute  drops  of  ammoniated  oil  min- 
gled with  the  aqueous  humour.  This  state  of  the  cornea  was  the 
consequence  of  pretty  severe  inflammation,  about  nine  months  be- 
fore, in  a  patient  who  had  long  been  troubled  with  rheumatism. 

The  appearance  of  the  redness  in  aquo-capsulitis,  so  far  resem- 
bles that  in  iritis,  that  there  is  a  circular  zone  of  minute  vessels 
seen  on  the  anterior  part  of  the  sclerotica.  Sometimes  one  or 
more  distinct  blood  vessels  are  seen  traversing  the  inflamed  mem- 
brane. Some  vessels  of  the  conjunctiva  also  are  frequently  en- 
larged. These  appear  as  insulated  trunks,  and  can  be  raised  on 
the  point  of  a  needle  from  the  sclerotica.  The  vessels  on  the  white 
of  the  eye  are  of  a  bright  red  colour  during  the  active  stage  of  the 
inflammation,  and  gradually  assume  a  more  crimson  hue  as  the 
symptoms  subside. 

There  sometimes  attends  this  disease  an  increased  flow  of  tears, 
but  the  patient  in  general  suffers  very  little  from  exposure  to  light. 

Vision  is  more  or  less  dim  ;  and  what  is  particularly  to  be  noted, 
is  a  sensation  of  distension  and  fulness  in  the  eyeball,  accompanied 
with  a  dull  aching  pain,  generally  in  the  forehead,  sometimes  also 
in  the  back  part  of  the  head  ;  symptoms  which  Mr.  Wardrop  as- 
sures us  are  instantly  and  permanently  relieved  by  evacuating  the 
aqueous  humour. 

The  constitutional  symptoms  vary  much  in  their  degree  of  se- 
verity. Sometimes  the  pulse  is  very  frequent  and  hard,  the  skin 
hot  and  dry,  the  tongue  loaded,  and  the  functions  of  the  alimentary 
canal  disordered.  In  other  cases,  the  disease  almost  from  the  com- 
mencement, assumes  a  chronic  form,  and  after  continuing  a  certain 
period,  participates  in  any  peculiarity  of  the  patient's  constitution, 
and  becomes  thereby  modified. 

During  the  continuance  of  the  inflammatory  symptoms,  there 
is  generally  so  much  muddiness  diflfused  over  the  whole  anterior 
chamber,  that  no  distinct  portions  of  eff"used  lymph  can  be  distin- 
guished, unless  they  be  of  large  size  ;  but  when  this  turbid  state 
goes  off",  flakes  of  lymph  may  sometimes  be  perceived,  and  in  other 
instances,  the  whole  surface  of  the  inflamed  membrane  is  left  cov- 
ered by  a  thin  layer  of  it.  In  some  cases,  the  effused  lymph  floats 
in  the  anterior  chamber,  appearing  like  a  thick  cloud ;  in  other 
cases,  it  is  deposited  in  streaks,  so  as  to  present  a  reticulated  ap- 
pearance ;  and  in  others,  it  resembles  a  purulent  fluid. 

If  the  eff'used  lymph  be  not  afterwards  absorbed,  it  is  apt  to  be- 
come organized ;  and  not  unfrequently  red  vessels  can  be  seen 
ramifying  through  it.  This  is  a  much  more  frequent  appearance 
than  that  to  which  I  have  already  referred,  of  a  red  vessel  or  vessels 


393 

running  along  the  internal  surface  of  the  cornea  without  any  effu- 
sion of  lymph. 

Treatment.  Little  else  is  known  regarding  the  effects  of  rem- 
edies in  this  rare  ophthalmia,  than  what  is  mentioned  by  Mr.  War- 
drop,  in  his  paper  on  Evacuation  of  the  Aqueous  Humour,  in  the 
fourth  volume  of  the  Medico-Chirurgical  Transactions.  In  the 
cases  there  recorded,  benefit  appears  to  have  been  derived  from 
cupping  the  temples,  purging,  fomenting,  and  the  application  of 
such  stimulants  as  murias  and  nitras  hydrargyri  in  solution,  red 
precipitate  salve,  and  sulphuric  ether.  Mr.  Wardrop,  however, 
places  most  reliance  on  the  evacuation  of  the  aqueous  humour, 
stating  that  there  is  no  inflammation  of  the  eye,  where  so  much 
benefit  is  derived  from  that  operation,  as  when  the  disease  affects 
the  internal  layer  of  the  cornea.  He  had  never  found  it  fail  in 
procuring  immediate  relief  of  the  pain  of  the  head,  and  instanta- 
neous restoration  of  the  transparency  of  the  anterior  chamber. 

The  opening  through  the  cornea,  by  which  the  aqueous  humour 
is  to  be  discharged,  may  be  made  with  any  of  the  knives  common- 
ly used  for  extracting  the  cataract,  or  with  a  broad  iris-knife.  It  is 
sufficient  that  the  point  of  the  instrument  be  introduced  so  that  it 
makes  a  puncture  into  the  anterior  chamber ;  this  should  be  done 
near  the  junction  of  the  cornea  and  sclerotica,  at  any  part  of  the 
circumference. 

When  the  knife  has  penetrated  into  the  anterior  chamber,  it  may 
be  withdrawn  a  little,  and  the  blade  turned  on  its  axis,  when  the 
aqueous  humour  will  readily  escape.  It  is  better  not  to  remove 
the  instrument  altogether,  till  the  fluid  is  observed  to  be  discharged ; 
for  if  the  incision  be  not  sufficiently  large,  and  the  knife  taken 
away  before  the  aqueous  humour  flows  out,  the  elasticity  of  the 
cornea  closes  the  wound,  and  either  hinders  the  evacuation  from 
being  so  sudden,  and  consequently  so  efficacious,  or  the  closure  of 
the  wound  entirely  prevents  its  escape.  The  operation,  therefore, 
which  is  necessary  to  discharge  the  aqueous  humour,  is  merely  the 
first  step  of  the  section  of  the  cornea,  made  in  extracting  the  cata- 
ract, or  what  is  called  the  puncturation. 

The  chief  difficulty  in  performing  the  operation,  arises  from  the 
pain  occasioned  by  the  necessary  pressure  on  the  eyeball,  whilst 
keeping  open  the  eyelids ;  but  until  a  sufficient  portion  of  the  cor- 
nea is  brought  into  view,  and  the  movements  of  the  eye  completely 
under  the  management  of  the  operator,  the  introduction  of  the 
knife  should  not  be  attempted.  The  upper  lid  should  be  elevated 
by  the  fingers  of  the  assistant,  or  by  Pellier's  speculum  ;  while  the 
operator,  with  the  fore  and  middle  fingers  of  the  hand  which  does 
not  hold  the  knife  presses  down  the  lower  lid,  and  applies  their 
points  over  its  edge,  in  such  a  manner  that  they  touch  the  eyeball, 
and  can  apply  any  degree  of  pressure  upon  it  which  may  be  neces- 
sary. After  the  assistant  raises  the  upper  hd,  the  patient  should  be 
60 


394 

directed  to  look  downwards  ;  and  then  the  assistant  employs  a  suf- 
ficient pressure,  to  keep  the  eye  in  that  position. 

The  operator  now  makes  the  puncture  ;  but  as  the  patient  is  very 
apt  to  start  when  he  first  finds  the  instrument  coming  in  contact  with 
his  e)'e,  it  is  useful  merely  to  touch  the  cornea  repeatedly  with  the 
back  of  the  knife  till  all  risk  of  starting  is  over  ;  and  as  soon  as  its 
extremity  rests  on  the  part  where  the  puncture  is  to  be  made,  the 
knife  may  readily  be  raised  on  its  point,  and  thrust  into  the  anterior 
chamber.* 

It  is  probable  that  a  variety  of  other  remedies  besides  those  men- 
tioned by  Mr.  Wardrop  might  be  useful  in  aquo-capsulilis  ;  es- 
pecially cinchona,  turpentine,  and  mercury.  Of  these,  however, 
nothing  can  be  said  from  experience. 


SECTION    XXV. INFLAMMATION    OF    THE    CRYSTALLINE    LENS 

AND    CAPSULE. 

Common  lenticular  cataract  appears  to  be  a  consequence  of  the 
impeded  nutrition  which  attends  the  advanced  period  of  life  ;  while 
opacities  of  the  capsule  are  probably  in  all  instances  the  result  of 
inflammation,  and  thus  resemble  specks  of  the  cornea.  Capsular 
and  capsulo-lenticular  cataracts  generally  present  themselves  to  our 
observation  after  the  inflanamation  in  which  they  have  originated 
has  subsided  ;  bat  in  other  cases,  we  may  be  fortunate  enough  to 
meet  with  the  disease  in  its  acute  stage.  The  appearances  which 
are  then  presented  to  observation,  have  been  minutely  described 
by  Professor  Wallher,*  and  I  have  had  more  than  one  opportu- 
nit)''  of  verifying,  to  a  certain  extent,  the  accuracy  of  his  descrip- 
tion. 

He  states  that  inflammation  of  the  crystalline  capsule  generally 
occurs  about  the  middle  of  hfe,  and  in  subjects  of  a  slight  cachectic 
disposition.  This  is  certainly  true,  although  in  more  than  one  in- 
stance I  have  seen  such  severe  inflammation  of  the  capsule  in 
young  children,  that  the  part  appeared  completely  loaded  with  red 
vessels.  This  disease  occurs  oftener  in  light  eyes  than  dark,  and 
is  always  accompanied  by  a  slight  chaoge  in  the  colour  of  the  iris 
and  form  of  the  pupil,  the  iris  becoming  a  little  darker,  and  the  pu- 
pil oval  or  irregular.  The  motions  of  the  iris  are  at  first  lively  and 
extensive,  but  subsequently  become  sluggish  and  very  hmited. 
The  pupil  is  smaller  than  in  the  sound  state,  and  there  usually 
appears  a  black  rim  of  irregular  breadth  all  round  its  edge,  arising 
from  the  pigmentum  nigrum  of  the  posterior  surface  af  the  iris  com- 
ing into  view. 

Along  with  these  symptoms,  a  number  of  red  vessels  appear  in 

•  Medico  Chirurgical  Transactions,  Vol.  iv.  p.  153.    London,  1813. 

*  Abhandlungen  aus  dem  Gebiete  der  practischen  Medicin.    Vol.  i.  p.  53.    Land' 
shut,  1810. 


395 

the  pupil  itself,  the  largest  of  which  are  visible  to  the  naked  eye,  but 
the  greater  number  distinguishable  only  by  the  aid  of  a  magnifying 
glass.  What  at  first  merely  appears  a  red  point,  assumes  under 
the  glass,  the  appearance  of  a  delicate  tissue  of  vessels.  The  lens 
used  for  this  microscopical  examination  of  the  eye  should  be  one  of 
a  very  short  focus,  and  the  patient  should  be  so  placed  with  respect 
to  the  light  that  the  parts  within  the  pupil  be  well  illuminated,  and 
not  shaded  by  the  glass  nor  by  the  head  of  the  observer.  In  order 
to  have  the  pupil  as  large  as  possible,  the  other  eye  should  be  closed 
during  the  examination,  and  a  little  of  a  filtered  solution  of  extract 
of  belladonna  in  water  should  be  dropped  upon  the  affected  eye  an 
hour  previously.  In  inflammation  of  the  capsule  of  the  lens,  the 
sensibility  not  being  much  increased,  the  patient  can  bear  exami- 
nation of  the  eye  in  a  strong  light  and  with  a  dilated  pupil,  without 
much  uneasiness. 

The  red  vessels  observed  in  the  pupil  during  inflammation  of 
the  anterior  hemisphere  of  the  capsule  always  constitute  a  sort  of 
vascular  wreath,  situated  at  about  a  quarter  of  a  line's  distance 
from  the  pupillary  edge  of  the  iris  ;  this  wreath  forms  a  concentric 
circle  within  the  pupil,  and  is  found  on  examination  to  consist,  not 
of  one  or  a  few  vessels  circularly  disposed,  but  of  a  number  of  vas- 
cular arches.  To  this  vascular  wreath  there  run  in  a  radiated 
form,  numerous  vessels  from  the  circumference  of  the  capsule. 
Other  vessels  seem  to  extend  from  the  pigmentum  of  the  iris ;  but 
such  are  not  constantly  present.  It  is  only  in  cases  where  the 
disease  has  lasted  some  considerable  time  that  they  appear.  In 
other  cases,  according  to  Professor  Walther,  vessels  seem  to  be  pro- 
longed rather  from  the  capsule  into  the  posterior  surface  of  the  iris. 
Those  which  run  from  the  iris  to  the  capsule,  never  aiise  from  the 
edge  of  the  pupil,  but  at  a  little  distance  from  it,  on  the  posterior 
surface  of  the  iris,  so  that  nearly  a  hue's  breadth  next  the  pupillary 
edge  is  free  from  these  vascular  sproutings. 

From  the  vascular  wreath  already  mentioned,  vessels  are  seen 
spreading  towards  the  centre  of  the  anterior  capsule,  and  these 
again  forming  clusters  and  arches.  The  continuation  between 
the  vessels  seen  indifferent  parts  of  the  pupil  seems  interrupt- 
ed at  some  points,  yet  there  can  be  no  doubt  of  their  being 
continuous;  although  from  their  extremely  minute  size  they  can 
be  distinguished  only  where  enlarged  and  clustering  together. 

Posterior  to  the  red  vessels  seen  in  the  capsule,  there  appears  in 
some  cases  a  network  of  more  delicate  vessels,  which  seem  to  be 
seated  in  the  lens  itself  The  larger  trunks  of  this  network  are 
not  always  derived  from  the  circumference  of  the  lens,  but  evidently 
come,  says  Professor  Walther,  from  its  posterior  surface,  directly 
forwards,  and  then  divide  into  branches.  The  presence  of  these 
vessels  in  the  lens,  he  has  repeatedly  and  distinctly  observed.  He 
states  that  they  present  one  of  the  most  beautiful  phenomena,  and 
that  the  only  things  which  come  near  them  are  the  finest  injections 


396 

of  the  choroid,  such  as  those  which  are  in  the  possession  of  Soem- 
mening,  and  have  been  represented  by  him  in  his  work  on  the 
anatomy  of  the  eye. 

Professor  Walther  is  of  opinion  thai  the  existence  of  these  vessels 
passing  into  the  substance  of  the  lens  is  entirely  morbid,  and  he 
compares  it  to  what  occurs  in  inflammation  of  the  thorax,  when 
vessels  are  prolonged  from  the  pleura  to  the  pseudo- membrane 
formed  on  its  surface.  He  says  that  as  the  vessels  of  the  anterior 
hemisphere  of  the  capsule  shoot  forwards  into  the  posterior  surface 
of  the  iris,  so  they  shoot  backwards  into  the  lens  itself;  and  that 
the  same  holds  good  with  respect  to  the  posterior  hemisphere  of  the 
capsule,  which  being  more  copiously  supplied  with  blood  vessels,  it 
is  explained  how  the  largest  vessels  of  the  lens  are  seen  to  come 
from  behind  forwards.  It  would  appear  also  that  all  inflammations 
of  the  lens  begin  in  the  capsule,  a  fact  which  Professor  W.  con- 
siders as  analogous  to  the  spread  of  inflammation  to  the  capsule 
from  the  ciliary  processes  or  from  the  iris. 

At  the  apparent  terminations  of  several  of  the  vessels  in  the  cap- 
sule, there  are  distinctly  perceived  httle  knots  of  a  whitish-grey 
semi-transparent  substance.  This  is  evidently  coagulable  lymph, 
and  Professor  W.  considers  its  presence  as  disclosing  the  manner 
in  which  inflammation  of  the  capsule  and  lens  produces  opacity 
of  these  parts.  The  anterior  hemisphere  of  the  capsule,  where  the 
vessels  are  very  numerous,  sometimes  assumes  a  peculiar  velvety 
or  flocculent  appearance,  and  in  one  or  more  spots  of  its  extent 
presents  a  grey  or  brownish  colour.  These  brownish  spots  appear 
in  some  instances  to  be  nothing  more  than  effused  lymph ;  but  in 
other  cases  they  probably  owe  their  origin  to  the  iiis  having  been 
united  to  the  capsule  by  partial  adhesions,  which  being  separated 
either  by  more  extensive  spontaneous  motions  of  the  iris,  by  me- 
chanical violence,  or  by  the  sudden  influence  of  belladonna  or  some 
similar  narcotic,  part  of  the  pigment  of  the  iris  has  remained  ad- 
herent to  the  anterior  surface  of  the  capsule. 

It  is  a  fact  strongly  confirming  the  accuracy  of  Professor  Wal- 
ther's  account  of  inflammation  of  the  crystalline  capsule,  that  in 
anterior  capsular  cataract,  the  specks  or  streaks  generally  radiate 
from  the  edge  of  the  anterior  hemisphere  of  the  capsule  towards  its 
centre ;  while  in  posterior  capsular  cataract,  they  evidently  branch 
out  from  the  centre  of  the  posterior  hemisphere,  following  thus  both 
the  natural  course  of  the  arteries,  and  the  directions  of  the  inflamed 
vessels,  as  represented  by  Professor  Walther. 

As  to  the  state  of  the  patient's  vision  who  is  affected  with  in- 
flammation of  the  lens  and  capsule,  where  the  disease  is  severe,  vis- 
ion is  indistinct  and  confused,  particularly  when  the  eye  is  directed 
towards  distant  objects.  Those  objects  which  are  nearer  are  seen 
as  if  through  a  fine  gauze.  This  does  not  seem  red,  nor  are 
objects  tinged  of  that  colour. 

This  ophthalmia  always  observes  a  chronic  course.     It  proceeds 


397 

very  slowly,  and  is  attended  with  little  or  no  pain.  When  pain 
does  attend  this  disease,  it  is  seated  at  the  bottom  of  the  orbit,  in  the 
forehead,  or  in  the  crown  of  the  head.  When  the  disease  has  con- 
tinued for  some  considerable  time,  the  blood  vessels  in  the  lens  and 
capsule  become  varicose  and  remain  so  permanently.  Professor  W. 
observed  the  vessels  of  the  lens  in  a  middle-aged  man.  to  remain  in 
a  varicose  state  for  a  whole  year,  without  undergoing  the  least  al- 
teration. In  one  case,  I  have  seen  this  disease  followed  by  incom- 
plete amaurosis,  with  tremulous  iris.  Effusion  of  fluid  between  the 
lens  and  capsule,  and  dissolution  of  the  former,  are  not  unfrequent 
consequences  of  inflammation  of  these  parts  ;  while  in  other  in- 
stances, this  disease  would  appear  to  go  the  length  of  suppuration, 
for  we  must  consider  inflammation  as  the  cause  of  that  variety  of 
cataract  which  is  called  cataracta  cum  bursa,  the  opaque  state  of 
the  lens  and  capsule  being  combined  with  the  presence  of  a  cyst 
contained  within  the  capsule  and  filled  with  pus. 

The  causes  of  this  ophthalmia  have  not  been  sufficiently  inves- 
tigated. In  one  case  which  came  under  my  care,  it  affected  the 
right  eye  of  a  keen  sportsman,  and  might  perhaps  be  connected  with 
the  over-excitement  which  the  eye  may  have  undergone  year  after 
year  at  the  shooting  season. 

Inflammation  of  the  lens  and  capsule  approaches  nearer  to  iritis 
than^to  any  other  ophthalmia.  It  is,  however,  much  less  acute  in  its 
character,  and  greatly  less  under  the  influence  of  treatment. 

Depletion,  counter-irritation,  and  alteratives,  are  the  remedies 
which  suggest  themselves  as  most  likely  to  do  good  in  the  early 
stage  of  this  disease,  and  tonics  in  the  latter  stages.  I  must  confess, 
however,  that  this  ophthalmia  has  in  my  hands  proved  the  most 
obstinate  of  any.  Even  mercury,  which,  in  the  inflammatory 
affections  of  the  eye  the  most  similar  to  this,  proves  almost  specific, 
appears  to  have  scarcely  any  power  over  the  inflamed  vessels  of  the 
crystalline  capsule. 


SECTION  XXVI. INFLAMMATION  OF  THE  HYALOID  MEMBRANE. 

The  morbid  states  in  which  we  meet  with  the  vitreous  humour, 
naturally  give  rise  to  the  supposition  that  it  occasionally  suffers  from 
inflammation.  Its  synchesis  or  dissolution,  dropsical  increase,  state 
of  atrophy,  unnatural  viscidity,  change  of  colour,  loss  of  transpa- 
rency, and  ossification,  are  so  many  morbid  changes,  which  lead  us 
to  suspect  the  hyaloid  membrane  to  be  susceptible  of  inflammation. 
The  vessels  of  the  posterior  hemisphere  of  the  crystalline  capsule 
are  derived  from  the  central  artery  of  the  vitreous  humour,  and  we 
can  scarcely  suppose  the  former  to  be  affected  with  inflammation, 
without  the  latter  participating  in  the  same  disease.  Inflammation 
of  the  hyaloid  membrane,  however,  has  not  been  observed  with 
sufficient  accuracy  ito  admit  of  description. 


398 


SECTION    XXVII. TRAUMATIC   OPHTHALMIA. 

We  have  now  seen  how  each  texture  of  the  eye  suffers,  in  its  own 
way,  from  intJammation,  excited  without  any  evident  mechanical 
or  chemical  injury  ;  the  conjunctiva  suffering  puro-mucous  and 
eruptive  diseases  ;  the  sclerotica,  rheumatic  disease  ;  the  iris  under- 
going adhesive  inflammation ;  the  cornea  losing  its  transparency, 
and  becoming  the  seat  of  purulent  infiltration  and  of  ulceration  j 
the  choroid  falling  into  a  state  of  extreme  varicosity ;  and  the  retina 
losing  its  sensibility  to  light ;  every  texture,  in  fact,  suffering  differ- 
ently. 

Now,  the  inflammation  which  is  excited  by  the  evident  mechani- 
cal or  chemical  injuries,  the  direct  effects  of  which  we  have  already 
considered,*  may  attack  one  or  several  of  these  textures.  We  may 
have  traumatic  conjunctivitis,  traumatic  corneitis,  traumatic  iritis, 
&.C.,  and  it  is  remarkable,  that  traumatic  inflammation,  in 
any  of  the  textures  of  the  eye,  imitates,  so  to  speak,  the  oph- 
thalmiae  which  we  have  already  considered.  We  meet  with 
puro-mucous  conjunctivitis,  excited  by  injury,  and  we  very  often 
see  pustular  or  phlyctenular  conjunctivitis,  brought  on  by  the  same 
cause.  Traumatic  iritis,  the  iritis,  for  example,  which  is  so  apt  to 
occur  after  the  operations  for  cataract,  very  closely  resembles  rheu- 
matic iritis.  The  cornea,  by  traumatic  inflammation,  is  rendered 
opaque,  or  becomes  affected  with  onyx,  or  with  ulceration  ;  the  lens 
also  loses  its  transparency  from  the  same  cause,  and  the  retina  its 
sensibility. 

This  observation,  if  duly  considered,  will  throw  a  great  degree 
of  light  on  the  treatment  of  the  traumatic  ophlhalmise.  Puriform 
inflammation  of  the  conjunctiva,  arising  from  injury,  is  to  be 
treated,  in  fact,  exactly  as  we  treat  catarrhal  ophthalmia.  In 
traumatic  iritis,  the  three  great  indications,  to  abate  the  inflamma- 
tory action  by  depletion,  to  dilate  the  contracting  pupil  by  bella- 
donna, and  to  promote  absorption  by  mercury,  are  to  be  followed 
out  exactly  as  in  rheumatic  or  syphilitic  iritis. 

For  these  reasons,  I  thought  it  proper  to  say  nothing  of  the 
traumatic  ophthalmia,  till  we  had  finished  the  consideration  of  the 
varieties  of  inflammatory  disease,  which  are  excited  in  the  different 
textures  of  the  eye  by  atmospheric  and  constitutional  causes. 
Without  a  knowledge  of  these  varieties  of  ophthalmia,  we  should 
be  but  httle  able  to  understand  the  inflammatory  effects  of  evident 
mechanical  and  chemical  injuries  upon  the  several  structures  com- 
bined in  the  eye  ;  but  with  such  a  knowledge,  both  the  symptoms 
and  the  treatment  of  the  traumatic  ophthalmiae  become  perfectly 
simple.  The  symptoms  vary,  no  doubt,  ad  wjinitum,  in  regard 
to  severity,  while  in  one  case,  a  single  texture,  and  in  other  cases, 
several  textures  of  the  eye  will  sufffer;  still,  the  invariable  and 

•  See  Section  1  of  Chapter  IV,  and  Chapter  IX. 


399 

peculiar  physical  and  vital  properties  of  each  texture  serve  to  pro- 
duce, under  wiiatever  circumstances,  or  by  whatever  causes  inflam- 
mation may  be  excited,  the  same  essential  phenomena. 

The  most  important  general  rule  regarding  the  treatment  of  the 
traumatic  ophthalmia,  is,  that  we  should  be  on  our  guard  against 
effects  which  are  apt  to  be  produced,  but  which  may  not  yet  be 
present,  and  against  effects  implicating  the  interior  textures  of  the 
organ,  although  the  injury  has  appeared  to  be  merely  superficial. 
A  considerable  part  of  our  treatment  must  be  preventive.  We 
must  not  wait  to  take  away  blood,  till  severe  sclerotitis,  with  acute 
circum-orbital  pain,  sets  in.  We  ought  to  bleed  from  the  moment 
of  a  severe  injury.  We  must  not  wait  till  the  pupil  is  evidently 
closing  ;  but  apply  belladonna,  and  prevent  it.  We  must  not  wait 
till  the  iris  grows  discoloured,  or  lymph  is  effused  into  the  pupil; 
but  from  the  very  first  put  the  patient  on  calomel  and  opium,  if  we 
apprehend  from  the  nature  of  the  injury,  that  iritis  is  hkely  to  be 
the  result. 

We  sometimes  meet  with  severe  sympathetic  inflammation  in 
the  eye  which  has  not  received  the  injury. 

It  is  not  unworthy  of  observation,  that  after  all  the  other  symp- 
toms of  severe  inflammation  of  the  eye  following  mechanical  or 
chemical  injuries  have  been  removed  by  depletion,  counter-irritation, 
mercurializalion,  &c.  a  very  troublesome  and  obstinate  intolerance 
of  light,  with  epiphora,  is  apt  to  remain,  not  so  much  apparently 
from  irritation  arising  from  the  state  of  the  eye,  as  merely  from 
continued  and  now  habitual  excessive  activity  in  the  hds  and  lach- 
rymal gland.  In  such  cases,  in  addition  to  the  remedies  recom- 
mended for  epiphora  at  page  76,  I  have  derived  advantage  from 
the  internal  use  of  the  extract  of  stramonium. 


SECTION    XXVIII. COMPOUND    OPHTUALMIjE. 

Strictly  examined,  few  instances  of  ophthalmise  will  be  found 
absolutely  simple.  Many  are  strikingly  compound  ;  for  example, 
the  catarrho-rheumatic,  already  described.  Strumo-catarrhal  oph- 
thalmia is  also  very  common,  beginning  as  a  slight  puro-mucous 
conjunctivitis,  but  soon  manifesting  the  signs  of  phlyctenular  oph- 
thalmia. In  other  cases,  we  meet  with  pustules  of  the  conjunctiva, 
combined  from  the  commencement  with  blenorrhoeal  inflammation 
of  that  membrane.  Phlyctenular  conjunctivitis  with  strumous 
iritis,  strumous  corneitis  with  iritis,  and  many  other  compound 
ophthalmise  might  be  enumerated. 

The  treatment  of  such  diseases  will,  of  course,  consist  in  the 
combined  use  of  the  means,  which  are  ascertained  1o  be  effectual 
in  removing  the  separate  or  simple  ophthalmiae.  The  treatment 
necessary  for  strumous  ophthalmia  will  be  combined,  therefore,  with 
that  for  catarrhal  conjunctivitis,  in  the  Btrurao-catarrhal  cases ; 


400 


while  in  the  catarrho-rheumatic  ophthalmia,  the  remedies  for  rheu- 
matic inflammation  of  the  sclerotica  will  be  required  alon^  with 
those  for  blenorrhoeal  inflammation  of  the  conjunctiva;  and  so  on, 
in  the  other  compound  ophthalmiee. 


SECTION   XXIX. INTERMITTENT    OPHTHALMIA. 

Although  several  interesting  cases  have  been  recorded  of  oph- 
thalmiee  recurring  in  the  same  individual  after  longer  or  shorter 
intervals  of  time,  yet  I  doubt  whether  there  is  sufficient  ground  to 
admit  the  existence  of  any  disease  of  this  kind  so  regularly  peri- 
odic in  its  accession,  as  to  warrant  the  appellation  of  intermittent 
ophthalmia.  The  pain  which  attends  many  of  the  ophthalmise, 
is  undoubtedly  subject  to  regular  nocturnal  exacerbations,  but  this 
does  not  entitle  these  diseases  to  the  appellation  of  intermittent. 
By  an  intermittent  or  periodical  ophthalmia,  I  should  understand 
one  which  recurred  with  considerable  regularity  at  intervals  of 
weeks  or  months,  and  apparently  not  from  accident,  but  from  con- 
catenation with  the  revolutions  of  time ;  whereas,  if  we  examine 
the  cases  which  are  recorded  as  being  of  this  kind,  we  shall  find 
that  they  are  nothing  more  than  instances  of  some  particular  oph- 
thalmia recurring  more  or  less  frequently  in  the  same  individual, 
in  consequence  of  his  repeatedly  exposing  himself  to  the  same,  or 
to  some  similar  exciting  cause.  The  strumous  ophthalmia,  being 
that  which  is  most  apt  to  be  renewed  on  slight  exposures,  will  also 
more  frequently  than  any  other  inflammatory  disease  of  the  eye 
appear  to  be  periodic.  The  rheumatic,  catarrho-rheumatic,  and 
catarrhal  will  also  be  subject,  from  their  ready  occurrence  in  eyes 
once  affected  with  them,  to  the  same  suspicion.  1  have  frequently 
treated  patients  who  at  intervals  of  three  or  four  months,  or  once  a 
year  nearly  about  the  same  season  for  several  successive  years, 
had  suffered  an  attack  of  rheumatic  iritis ;  but  in  every  case  of 
this  kind,  I  have  been  able  to  trace  the  return  of  the  disease  to 
some  new  imprudence.  In  arthritic  inflammation  of  the  eyes,  the 
periodic  tendency  will  also  appear  to  be  very  decided,  for  every 
attack  of  that  sort  leaves  the  eyes  worse  than  before,  and  with  a 
strong  disposition  to  suffer  again  from  renewed  causes  of  excite- 
ment. 

These  remarks,  will,  I  think,  be  confirmed  by  a  careful  perusal 
of  the  interesting  narratives  of  Dr.  Curry  and  Dr.  Bostock,  both 
of  whom  had  suffered  from  repeated  attacks  of  severe  ophthalmise.* 

*  History  of  a  Case  of  Remitting  Ophthalmia,  and  its  successful  Treatment  by 
Opium ;  by  James  Curry,  M.  D.  in  the  Medico-Chirurgical  Transactions,  Vol.  iii.  p. 
3^.  London,  1812. — Case  of  a  Periodical  Affection  of  the  Eyes  and  Chest ;  by  John 
Bostock,  M.  D.  in  the  same  work,  Vol.  x.  p.  161.     London,  1819. 


401 


CHAPTER  XL 
DISEASES  CONSEQUENT  TO  THE  OPHTHALMI.E. 

Some  of  the  consequences  of  the  ophthahniae  are  immediate,  while 
others  are  more  or  less  remote.  Onyx,  for  example,  or  effusion  of 
matter  between  the  lamellae  of  the  cornea,  is  an  immediate  conse- 
quence of  severe  inflammation  of  the  exterior  textures  of  the  eye  ; 
hernia  of  the  iris  is  a  remote  consequence,  which  cannot  take 
place  till  the  cornea  is  penetrated  by  ulceration  ;  while  staphyloma 
of  the  iris  and  cornea  is  still  more  remote,  never  being  produced 
till  these  two  parts  are  united  by  inflammation,  and,  in  many 
cases,  not  for  a  considerable  number  of  weeks  or  months  after  such 
union  is  effected. 

In  all  the  cases  falUng  under  the  head  of  diseases  consequent 
to  the  ophthalmise,  it  is  a  question  of  importance,  Is  the  ophthal- 
mia subdued  ?  If  it  is  not,  then  the  remedies  which  are  indicated 
in  the  particular  species  of  ophthalmia,  which  is  still  present,  how- 
ever long  it  may  have  continued,  and  however  much  it  may  have 
been  neglected  or  mistreated,  are,  in  all  probability,  the  most  likely 
means  to  remove  also  the  consequences  which  the  ophthalmia  has 
produced.  If,  on  the  other  hand,  all  active  inflammatory  symp- 
toms are  gone,  and  merely  certain  sequelae  remain  behind,  it  is 
often  necessary  to  try  some  mode  of  treatment  totally  different  from 
what  might  have  been  pursued  with  advantage,  had  the  disease 
still  existed  in  the  inflammatory  stage.  To  recur  again  to  onyx 
and  staphyloma,  as  illustrations,  we  have  frequent  opportunities  of 
witnessing  the  complete  dispersion  of  the  former  by  the  employ- 
ment of  proper  antiphlogistic  means,  while  the  latter  is  totally 
beyond  the  control  of  any  such  mode  of  treatment. 


SECTION    I. ONYX,    OR    ABSCESS    OP    THE    CORNEA. 

The  name  onyx  is  highly  expressive  of  the  state  of  the  cornea 
to  which  it  is  applied  ;  namely,  a  collection  of  matter  in  the  sub- 
stance, or  between  the  lamellae  of  that  part.  Such  an  abscess 
generally  makes  its  appearance  at  the  lower  edge  of  the  cornea, 
and,  however  small,  may  easily  be  distinguished  from  commencing 
hypopium,  by  its  exact  similarity  in  form  to  the  small  white  spot 
seen  at  the  root  of  the  nails,  whence  the  name.*  Even  when  the 
quantity  of  pus  between  the  lamellae  of  the  cornea  is  more  consid- 
erable, this  disease  may  always  be  known  by  its  superior  limit 
being  circular,  and  by  its  remaining  unchanged  in  form  and  situ- 
ation, whatever  be  the  position  of  the  patient's  head  ;  whereas  hy- 

*  Ovu|,  the  nail. 

51 


402 

popium  always  presents  a  horizontal  limit  superiorly,  when  the 
patient  has  been  for  some  time  at  rest  in  the  erect  position,  although, 
upon  motion,  this  form  may  be  somewhat  changed,  by  the  matier 
gravitating  to  one  or  other  side,  according  to  the  direction  in  which 
the  head  is  moved. 

Onyx  is  apt  to  take  place  chiefly  in  acute  and  neglected  cases 
of  puro-miicous  ophthalmia,  and  especially  in  the  ophthalmia  of 
new-born  children.  It  occurs,  not  uufrequently,  in  catarrho-rheu- 
matic  ophthalmia,  and  in  variolous  ophthalmia  :  occasionally  in 
strumous  ophthalmia;  very  rarely  in  ony  of  the  others. 

Under  the  use  of  the  remedies  most  applicable  to  the  particular 
ophthalmia  in  which  it  originates,  onyx  is  frequently  removed  by 
absorption,  in  the  course  of  a  lew  days,  or  even  in  a  few  hours. 
But,  in  neglected  cases,  more  and  more  matter  is  effused,  mount- 
ing gradually  from  the  lower  edge  of  the  cornea  till  it  covers  the 
pupil,  separating  the  lamellae,  or,  perhaps,  rather  infiltrating  the 
substance  of  the  cornea,  till  at  length  this  part  of  the  eye  is  com- 
pletely put  on  the  stretch,  and  looks  like  an  abscess  ready  to  burst. 
As  the  onyx  thus  increases,  the  pain  of  the  eye  and  head  is  severe- 
ly aggravated.  At  length,  occasionally  the  posterior  lamellee  give 
way,  and  the  matter  is  thrown  into  the  anteiior  chamber,  so  as  to 
form  a  spurious  hj'popium  ;  but  more  frequently  ulceration  com- 
mences on  the  external  surface  of  the  cornea,  and  over  the  middle 
of  the  onyx  ;  in  the  progress  of  ulceration,  the  cavity  containing 
the  pus  is  opened,  and  slowly  the  matter  is  discharged.  As  the 
onyx  increases,  the  pupil  uniformly  contracts,  and  becomes  filled 
with  lymph.  Not  unfrequently,  the  ulcer  which  has  served  to  open 
the  onyx  goes  on  to  penetrate  completely  through  the  cornea,  so 
that  the  aqueous  humour  is  discharged,  the  iris  falls  forward  into 
contact  with  the  ulcerated  cornea,  adhesion  between  them  ensues, 
and  the  case  ends  in  staphyloma.  The  result,  however,  of  the 
bursting  of  an  onyx  externally,  is  not  always  so-  unfortunate.  It 
not  unfrequently  happens,  tliat  as  soon  as  its  contents  are  dis- 
charged, the  inflammation  begins  to  subside,  the  pupil  clears,  and, 
although  some  degree  of  leucoma  is  always  left,  it  may  be  very 
limited,  so  that  a  fair  degree  of  vision  shall  be  preserved. 

Although  the  lower  edge  of  the  cornea  is  by  far  the  most  fre- 
quent seat  of  incipient  onyx,  it  sometimes  happens  that  pus  is  col- 
lected in  a  circumscribed  spot  over  the  pupil,  or  at  any  other  part 
of  the  cornea,  while,  in  other  cases,  we  see  onyx  commencing,  per- 
haps, above  the  centre  of  the  cornea,  and  diffusing  itself  irregularly 
over  a  large  extent.  This  is  particularly  the  case  with  onyx  orig- 
inating in  a  variolous  or  strumous  pustule,  which  has  burst  into  the 
cornea,  and  not  through  its  exterior  lamellae.  Such  an  onyx  is 
generally  absorbed  after  a  considerable  length  of  lime,  the  lamellae 
which  were  separated  by  its  presence  come  together  again,  adhere 
by  means  of  effused  lymph,  and  present  a  peculiar  variety  of  albu- 
go, which  seldom  entirely  disappears. 


403 

Treatment.  The  remedies  most  likely  to  subdue  the  ophthal- 
mia ill  which  the  onyx  has  originated,  must  be  carefully  employed. 
Nuuseants,  purgative.^,  counter-irritation,  and  mercurialization,  he- 
sides  their  antiphlogistic  powers,  frequently  appear  to  act  favourably 
by  promoting  the  absorption  of  the  purulent  effusion  in  these  ab- 
scesses of  the  cornea.  Belladonna  ought  to  be  used  to  counteract 
the  tendency  to  contraction  of  the  pupil. 

Ought  abscesses  of  the  cornea  to  be  evacuated  by  the  knife? 
All  agree  that  this  ought  never  to  be  ventured  on,  when  they  are 
small,  that  is  to  say,  when,  having  commenced  at  the  lower  edge 
of  the  cornea,  they  have,  perhaps,  not  mounted  higher  than  oppo- 
site to  the  lower  edge  of  the  pupil,  in  its  medium  state  of  dilatation. 
Larger  onyces  than  this  I  have  repeatedly  opened  with  the  lancet, 
and  in  every  case  in  which  I  have  done  so,  staphyloma  has  been 
the  unfortunate  result.  I  have,  on  the  other  hand,  left  onyces  un- 
touched, although  they  were  so  extensive  as  to  cover  the  pupil 
completely,  and  have  sometimes  had  the  satisfaction  of  witnessing 
an  almost  perfect  recovery  of  the  eye.  The  following  is  a  case 
which  I  treated  on  this  plan,  at  the  Eye  Infirmary. 

John  Ferrie,  aged  47,  was  admitted  on  the  22d  of  May,  1826,  on 
account  of  catarrho-rheumatic  ophthalmia  of  the  left  eye,  with 
which  he  had  been  affected  for  about  three  weeks.  For  eight  days 
he  had  had  severe  orbital  pain  during  the  night.  There  was  an 
onyx,  extending  from  the  lower  edge  of  the  cornea  go  high  as  to 
cover  the  pupil,  and  over  the  middle  of  the  onyx  there  was  a  small 
ulcer.  The  conjunctiva  and  sclerotica  were  very  vascular.  Vinum 
opii  was  dropped  upon  the  eye,  and  extract  of  belladonna  smeared 
on  the  eyebrow  and  lids.  He  was  ordered  to  rub  the  forehead  and 
temple  every  night  with  tincture  of  opium,  to  bathe  his  feet  in  hot 
water,  and  to  take  two  grains  of  calomel  with  one  of  opium,  on 
going  to  bed.  On  the  24th,  he  felt  the  eye  better,  although  there 
was  not  much  evident  change  in  its  appearance.  The  iris  was 
discoloured,  and  there  was  a  lymphatic  effusion  into  the  pupil.  He 
was  ordered  to  take  the  calomel  and  opium  morning  and  evening, 
to  apply  a  blister  to  the  nape  of  the  neck,  and  to  continue  the  other 
remedies.  On  the  27th,  the  mouth  was  affected,  but  the  onyx  had 
increased.  Eight  leeches  were  applied  to  the  left  temple  ;  the 
morning  dose  of  calomel  and  opium  was  omitted.  On  the  31st, 
the  pupil  appeared  to  be  contracting.  On  the  2d  of  .Tune,  the  up- 
per part  of  the  cornea  was  observed  to  be  nebulous,  and  the  eye  felt 
more  uneasy.  The  nitras  argenti  solution  was  applied  in  place  of 
the  vinum  opii.  By  the  5th.  the  exterior  laminae  of  the  cornea  had 
given  way,  and  a  considerable  quantity  of  matter  had  been  dis- 
charged from  the  onyx.  The  pupil  was  still  more  contracted. 
He  complained  of  a  feeling  of  sand  in  the  eye.  He  was  ordered  an 
aqueous  solution  of  extract  of  belladonna,  as  a  collyrium.  On  the 
7th,  the  blister  was  reapplied.  By  the  9th,  the  aqueous  humour 
had  evacuated  itself,  and  the  iris  fallen  forward  into  contact  with 


404 

the  cornea.  The  matter  of  the  onyx  had  almost  entirely  disap- 
peared, and  he  said  he  saw  a  httle  better.  On  the  12th,  the  pupil, 
still  in  contact  with  the  cornea,  appeared  clearer,  and  vision  was 
more  distinct.  On  the  14th,  a  little  aqueous  humour  was  present 
between  the  upper  part  of  the  iris  and  cornea  ;  the  ulcer  of  the  cor- 
nea was  covered  with  lymph  ;  and  all  the  pus  gone.  On  the  26th, 
the  pupil  was  considerably  larger,  and  clear ;  more  aqueous  hu- 
mour was  present  between  the  iris  and  cornea.  By  the  30th,  the 
pupil  was  clear,  and  of  considerable  size.  A  minute  adhesion  be- 
tween the  slight  leucoma  on  the  cornea  and  the  lower  edge  of  the 
pupil  was  observed,  when  the  eye  was  examined  laterally.  The 
vision  of  the  eye  was  good. 

In  this  case,  then,  I  left  the  abscess  of  the  cornea  to  itself,  and 
certainly  no  case  could  have  been  more  alarming  in  its  progress, 
nor  more  unexpectedly  favourable  in  its  results.  The  success  which 
attended  this  case,  I  attributed  in  a  great  measure,  to  the  sorbefa- 
cient  influence  of  the  calomel  over  the  effusion  into  the  pupil,  to  the 
continued  use  of  belladonna,  and  to  the  gradual  and  natural  pre- 
paration of  the  cornea  for  its  giving  way,  and  for  its  healing  up — 
a  preparation  which  would  have  probably  been  altogether  defeated, 
had  I  ventured  to  open  the  onyx  with  the  lancet. 

In  cases,  however,  where  the  abscess  does  not  incline  to  open  of 
itself,  but  appears  to  be  about  to  involve  the  whole  cornea,  an  artifi- 
cial exit  must  be  afforded  to  the  matter,  were  it  merely  to  save  the 
patient  from  the  continuance  of  the  violent  pain  which  attends  this 
symptom.  The  incision  may  be  made  conveniently  with  the  iris- 
knife,  and  ought  to  comprehend  only  the  external  laminse  of  the 
cornea.  At  the  moment  of  making  the  incision,  no  pus  is  in  gen- 
eral discharged,  but  it  forms  in  the  course  of  some  minutes  a  small 
drop,  which  is  to  be  wiped  away  from  the  cornea.  The  operation, 
in  most  cases,  requires  to  be  several  times  repeated,  before  the  onyx 
is  entirely  evacuated,  and  ought  to  be  held  out  to  the  patient  more 
as  a  palliative  for  the  pain,  than  as  a  means  of  saving  the  sight, 
which,  in  such  circumstances,  is  generally  lost. 

The  effect  of  evacuating  the  aqueous  humour  in  the  early  stages 
of  onyx  does  not  appear  to  be  ascertained.  Although  by  no  means 
disposed  to  regard  that  operation  as  one  frequently  called  for  in  the 
treatment  of  the  ophthalmise,  nor  as  one  altogether  free  in  itself 
from  danger,  I  am  willing  to  acknowledge  that  it  must,  at  least  for 
a  short  time,  relieve  the  tension  which  attends  severe  inflammations 
of  the  eye,  and  that  as  onyx  makes  its  appearance  only  in  severe 
cases,  the  evacuation  of  the  aqueous  humour  in  the  mode  described 
at  page  393,  might  have  a  good  effect  upon  this  dangerous  symp- 
tom. To  trust,  however,  almost  solely  to  this,  or  to  any  other  local 
means,  without  assiduously  combating,  by  general  means,  the 
ophthalmia  in  which  the  onyx  has  originated,  would  be  highly  im- 
proper. 


405 


SECTION  II. — hypopidm; 

1.  By  true  hypopium  is  meant  a  collection  of  matter  within  the 
chambers  of  the  aqueous  humour,  and  most  frequently  within  the 
anterior  chamber,  secreted  by  some  portion  of  the  parietes  of  these 
cavities,  as  the  lining  membrane  of  the  cornea,  the  iris,  the  capsule 
of  the  lens,  or  the  ciliary  processes. 

The  most  frequent  sources  of  true  hypopium  appear  to  be  the 
iris  and  the  cornea.  In  this  variety  of  abscess,  the  purulent  matter 
is  always  observed  first  at  the  bottom  of  the  anterior  chamber,  and 
so  long  as  the  patient  remains  at  rest  in  the  erect  position,  its  su- 
perior limit  constantly  presents  a  horizontal  line.  In  some  cases  it 
is  seen  to  shift  its  position,  on  inclination  of  the  head  from  side  to 
side ;  while,  in  other  instances,  it  is  so  thick  and  glutinous,  that  it 
undergoes  no  change  of  this  kind.  It  may  increase  gradually  till 
it  not  merely  covers  the  pupil,  but  completely  fills  the  anterior 
chamber.  If  the  case  be  neglected,  the  prominence  of  the  cornea 
increases,  it  becomes  conical,  presents  exactly  the  appearance  of  an 
abscess,  and  at  last,  under  a  scarcely  supportable  degree  of  pain, 
gives  way ;  the  pain  now  ceases,  the  iris  falls  forward  and  adheres 
to  the  cornea,  and  staphyloma  is  the  result. 

It  is  but  rarely  that  we  meet  with  true  hypopium,  uncombined 
with  some  affection  of  the  cornea,  and  still  more  rarely  does  it  pro- 
ceed, unless  complicated  with  onyx  or  ulcer  of  the  cornea,  to  such  a 
degree  as  to  give  rise  to  rupture  of  the  cornea.  Most  frequently 
the  collection  of  purulent  matter  remains  nearly  the  same  in  quan- 
tity, not  only  for  several  days,  but  even  weeks  ;  during  which  time 
the  iris  becomes  more  and  more  inflamed,  its  motions  more  and  more 
impeded,  and  at  last,  when  the  matter  is  absorbed,  the  pupil  is 
found  to  be  almost  entirely  obliterated.  When  onyx,  or  ulcer  of 
the  cornea,  is  present  along  with  true  hypopium,  there  is  much 
danger  of  the  cornea  being  destroyed,  and  the  case  ending  in  sta- 
phyloma. 

2.  The  name  spitrious  hi/popium  is  applied  to  a  collection  of 
pus  in  the  anterior  chamber,  arising  from  the  bursting  of  an  abscess 
of  the  iris  or  of  the  cornea  into  that  cavity.  Abscess  of  the  iris  I 
have  already  described  at  page  360,  and  abscess  of  the  cornea  in 
the  last  section.  Hypopium  of  this  sort  seldom,  if  ever,  reaches 
higher  than  the  lower  edge  of  the  pupil.  When  onyx,  however, 
exists  along  with  true  hypopium,  and  bursts  into  the  anterior  cham- 
ber, this  cavity  may  become  completely  filled  with  pus. 

Treatment.  The  remarks,  in  the  last  section,  on  the  treatment 
of  onyx,  apply,  almost  without  any  variation,  to  that  of  hypopium. 
The  inflammation  must  be  combated  by  general  means,  and  in  its 
subsidence  we  must  chiefly  trust  for  the  removal  of  the  purulent 
effusion. 

The  giving  exit  to  the  matter  of  hypopium,  by  an  incision  of 
the  cornea,  is  plainly  advisable  in  every  case  in  which  the  chambers 


406 

are  completely  filled,  for  we  can  never  depend,  in  such  a  case,  on 

absorption  ;  while,  by  delay,  we  should  risk  the  bursting-,  and 
complete  destruction  of  the  eye.  Under  such  circiuiistances,  we 
must  regard  the  opening  of  the  cornea  as  notliing  more  than  a 
means  of  freeing-  the  patient  from  excessive  pain,  and  of  preserving 
such  a  form  of  the  eyeball,  as  may  afterwards  permit  the  application 
of  an  artificial  eye. 

When  the  hypopium  does  not  amount  to  such  a  quantity  of  mat- 
ter as  to  fill  the  chambers  of  the  eye,  and  especially  when  severe 
inflammation  of  the  iris  is  present,  it  might  seem  improper  to  prac- 
tice an  opening  of  the  cornea.  Such  an  operation  appears  likely  to 
aggravate  the  intlammation,  increase  the  secretion  of  purulent 
matter,  and  expose  the  eye  to  protrusion  of  the  iris.  Notwith- 
standing these  apparent  objections.  Mr.  Wardrop  has  recommend- 
ed evacuation  of  the  aqueous  humour,  as  a  remedy  of  much 
service,  in  the  early  stages  of  hypopium ;  and  in  cases  of 
iritis,  and  of  ulcer  of  the  cornea,  combined  with  hypopium, 
we  have  the  testimony  of  Dr.  Monteath  in  favor  of  a  similar  prac- 
tice. One  of  the  apparent  objections  to  it  is  easily  removed,  even 
by  theoretical  considerations,  namely,  the  dread  of  protrusion  of  the 
iris  ;  for,  in  hypopium,  the  iris  is  always  in  a  state  of  inflammation, 
with  a  tendency  to  contraction  of  the  pupil,  which  will,  1  believe, 
prevent  any  protrusion  from  taking  place. 

Dr.  Monteath  recommends  the  incision  to  be  made  with  the 
iris-knife,  and  to  be  two  or  three  lines  in  length.  This  extent  of 
incision  is  necessary,  on  account  of  the  purulent  exudation  being 
thick,  and  sometimes  even  adherent,  so  that  it  will  not  flow 
out,  but  require  to  extracted  by  forceps,  or  a  small  blunt  hook. 
Dr.  M.  mentions,  that,  after  opening  the  cornea,  and  laying  hold  of 
a  small  filament  of  the  matter,  he  has  often  been  able  to  extract  the 
whole  en  masse,  which,  previously  examined  through  the  cornea, 
had  every  appearance  of  pus,  but  when  extracted  and  examined, 
was  in  every  respect  similar  to  the  exudation  of  puriform  13'mph, 
on  the  surface  of  an  inflamed  pleura  or  peritmieum.  He  observes, 
that  when  the  hypopium  is  considerable,  the  operation,  repeated 
again  and  again  if  necessary,  checks  the  suppuration  and  ulcera- 
tion of  the  internal  surface  of  the  cornea  which  invariably  takes 
place  when  the  collection  mounts  as  high  as  the  centre  of  the  pupil, 
and  which  is  so  apt  to  end  in  bursting  of  the  cornea,  and  destruc- 
tion of  the  eye,* 


SECTION  III. ULCERS,  DIMPLE,  HERNIA,  AND  FISTULA  OF  THE 

CORNEA,  AND  HERNIA  OF  THE  IRIS. 

1.  There  are  two  distinct  varieties  of  ulcer  of  the  cornea,  the  su- 
perficial and  the  deej). 

*  Glasgow  Medical  Journal,  Vol.  ii.  p.  122.    Glasgow,  1829. 


407 

The  former  generally  extends  over  a  considerable  portion  of  the 
surface  of  the  cornea,  appearing  often  to  destroy  merely  its  conjunc- 
tival covering.  The  deep  ulcer  is  commonly  much  less  extensive, 
but  aflects  the  proper  substance  of  the  cornea,  and  often  penetrates 
completely  through  it,  so  as  to  open  into  the  anterior  chamber,  and 
give  exit  to  the  aqueous  humour.  The  superficial  ulcer  occurs 
much  more  frequently  in  catarrho-rheumatic  ophthalmia,  than  in 
any  other ;  the  deep  is  generally  the  result  of  the  bursting  of  a  stru- 
mous phlyctenula  or  pustule.  The  superficial,  however,  sometimes 
arises  from  slight  mechanical  or  chemical  injury,  while  the  deep  is 
occasionally  owing  to  more  severe  injury  of  the  same  kinds.  Onyx 
bursting  externally  also  gives  rise  to  deep  ulcer  of  the  cornea. 

The  superficial  ulcer  of  the  cornea  discharges  only  a  thin  clear 
kind  of  matter,  its  surface  is  slightly  rough,  its  edges  are,  in  general 
very  irregular,  and  so  little  raised  above  the  level  of  the  ulcer,  that 
in  many  cases  merely  the  conjunctival  layer  of  the  cornea  appears 
as  if  abraded.  The  cicatrice  which  follows  such  an  ulcer  is  usually 
quite  transparent,  so  that,  at  least  for  some  time,  the  appearance  is  as 
if  a  portion  of  the  cornea  had  been  sliced  off. 

The  deep  ulcer,  on  the  other  hand,  is  small,  circular,  and,  by 
penetrating  the  laminee  of  the  cornea,  one  after  the  other,  comes  to 
present  a  funnel-shape.  Its  surface  is  usually  ragged  and  covered 
with  a  sloughy-like  matter,  which  assumes  a  white  colour  if  touched 
by  any  lotion,  or  other  preparation,  containing  sugar  of  lead.  'J'he 
same  happens  to  the  superficial  ulcer,  which  becomes  covered  by  an 
opaque  cicatrice  in  consequence  of  the  use  of  saturnine  applications. 
Hence,  in  every  case  of  ulcer  of  the  cornea,  these  applications  ai"e 
totally  inadmissable.  The  cicatrice  which  follows  the  healing  up  of 
a  deep  ulcer  of  the  cornea  is  always  opaque. 

2.  There  is  one  pecuhar  appearance  on  the  cornea  which  must 
not  be  confounded  with  these  ulcers  ;  namely,  that  state  of  it  which 
follows  the  absorption  of  a  phlyctenula  or  pustule.  The  result  of 
such  absorption  is  a  transparent  dimple,  smooth,  and  covered  in  fact 
by  the  conjunctiva,  which  has  fallen  down  into  the  little  depression, 
formed  by  the  removal  of  the  contents  of  the  phlyctenula  or  pus- 
tule. 

3.  Occasionally  it  happens  that  the  progress  of  a  deep  ulcer  is  ar- 
rested by  the  lining  membrane  of  the  cornea,  or  that  this  mem- 
brane, after  having  been  penetrated  by  the  ulcer,  heals  up,  but,  in 
either  case,  being  unable  by  itself  to  resist  the  pressure  of  the  aque- 
ous humour,  it  is  protruded  through  the  ulcer  in  the  form  of  a  vesi- 
cle, constituting  what  is  termed  hernia  of  the  cornea.  This  pro- 
trusion sometimes  takes  place  to  a  very  great  extent,  assuming  a 
conical  form,  and  rising  so  far  above  the  natural  level  of  the  cornea, 
as  with  difficulty  to  be  covered  by  the  eyelids.  In  such  cases,  we 
are  obliged  to  remove  it  with  the  scissors,  or  destroy  it  by  the  csppli- 
cation  of  lunar  caustic  ;  and  what  is  very  remarkable,  a  similar  pro- 
trusion is  apt  to  return  again  and  again,  even  in  the  course  of  a  few 


408 

days  after  we  have  completely  removed  the  preceding,  till  at  length 
the  cicatrized  cornea  attains  a  degree  of  firmness  sufficient  to  resist 
the  pressure  of  the  aqueous  humour. 

4.  When  an  ulcer  fairly  penetrates  through  the  cornea,  the  aque- 
ous humour  is  suddenly  discharged,  the  iris  falls  forward,  and  but 
too  often  becoming  engaged  in  the  ulcer,  protrudes  through  it, 
forming  a  little  black  point  like  the  head  of  a  fly,  whence  the  name, 
myo-cephalon,  which  is  bestowed  on  this  hernia  of  the  iris.  The 
bit  of  iris  which  protrudes  speedily  adheres  to  the  ulcer,  and  should 
violent  inflammation  of  the  eye  continue  after  this  accident,  the  iris 
and  cornea  are  very  apt  to  become  agglutinated  together  in  a  great 
part  of  their  extent,  and  ultimately  to  become  staphylomatous. 

5.  It  may  not  be  improper  here  to  notice,  what  is  termed  fistula 
of  the  cornettj  although  it  very  rarely  resuks,  except  from  perforat- 
ing injuries  of  the  part.  An  artificial  wound  of  the  cornea,  such  as 
the  section  made  for  extraction  of  the  cataract,  sometimes  remains 
long  open,  and  threatens  to  become  callous  and  fistulous  ;  a  perfor- 
ating ulcer  of  the  centre  of  the  cornea  may  also  fall  into  a  similar 
state,  and  allow  the  aqueous  humour  to  drain  away  for  a  number  of 
days.  These  may  so  far  be  considered  as  instances  of  fistula  of  the 
cornea  :  but  the  most  remarkable  affection  of  this  sort  occurs  when 
a  perforating  wound,  close  to  the  edge  of  the  sclerotica,  and  entering 
the  anterior  chamber,  becomes  closed  by  the  conjunctiva  healing 
over  it,  although  the  cornea  continues  imperfect,  so  that  the  aqueous 
humour  flows  out  under  the  conjunctiva,  and  elevates  it  in  the  form 
of  a  vesicle.  If  this  swelling  be  removed  with  the  scissors,  a  large 
quantity  of  thin  fluid  escapes,  and  at  the  bottom  of  the  opened  cj'^sty 
an  orifice  will  be  detected,  leading  directly  into  the  anterior  cham- 
ber. If  nothing  further  is  done,  the  conjunctiva  heals,  but  the  fis- 
tula corneae  remains,  and  the  vesicular  sweUing  returns.* 

Both  kinds  of  ulcer  of  the  cornea,  but  especially  the  deep,  are 
usually  attended  by  much  intolerance  of  light,  and  a  gush  of  burn- 
ing tears  on  opening  the  eyelids. 

The  subjects  of  ulcer  of  the  cornea,  and  especially  of  the  deep 
ulcer,  are  rarely  robust  or  in  a  good  state  of  general  health.  On 
the  contrary,  they  frequently  present  the  indubitable  signs  of  great 
weakness,  and  sometimes  even  of  inanition,  so  that  I  have  occa- 
sionally been  led  to  compare  their  state  to  that  of  the  dogs  in  Ma- 
gendie's  experiments,  which  being  fed,  or  rather  starved,  on  white 
sugar  and  distilled  water,  died  from  exhaustion,  their  death  being 
preceded  by  perforating  ulcer  of  the  cornea  and  evacuation  of  the 
humours.t     The  girl,  whose  case  I  have  related  at  page  327,  was 

*  See  a  Case  of  Fistula  Corneae,  which  I  treated  at  the  Eye  Infirmary,  reported  in 
the  London  Medical  Gazette,  Vol.  v.  p.  224.     London,  1829. 

t  Memoire  sur  les  Proprietes  nutritives  des  Substances  qui  ne  contiennent  pas 
d' Azote,  p.  7.  Paris,  1816. — See  a  Case  of  Ulcerated  Cornea,  from  Inanition:  by 
Joseph  Brown,  M.D.  in  the  Edinburgh  Journal  of  Medical  Science,  Vol.  iiL  p.  218» 
Edinburgh,  1827. 


409 

in  a  state  of  great  debility  in  consequence  of  over-depletion.  With- 
in 24  hours,  the  tonic  plan  of  treatment  arrested  the  progress  of  a 
deep  ulcer  on  one  of  her  cornese. 

Treatment.  In  all  cases  we  endeavour,  of  course,  to  check  the 
ulcerative  process,  by  those  measures  which  are  fitted  for  subduing 
the  inflammation  in  which  the  ulcer  took  its  origin.  So  long  as 
there  is  an  appearance  of  activity  in  the  inflammatory  disease,  and 
much  pain  of  the  eye,  local  blood-letting  must  be  employed.  The 
bowels  must  be  kept  freely  open,  and  opium  administered  in  such 
a  combination  as  shall  be  likely  to  operate  on  the  skin.  In  stru- 
mous cases,  sulphate  of  quina  operates  very  advantageously.  In 
chronic  superficial  ulcer,  calomel,  given  so  as  to  affect  the  mouth, 
is  sometimes  necessary.  In  almost  all  cases  of  ulcerated  cornea, 
counter-irritation  will  be  found  useful.  As  the  inflamed  state  of 
the  eye  abates,  the  patient  finds  the  pain  greatly  relieved^  and  we 
observe  the  ulcer  clearing  and  beginning  to  contract. 

It  frequently  happens,  however,  that  the  ulcer  itself  proves  a 
principal  cause  of  prolonging  the  inflammation.  The  flow  of  acrid 
tears,  and  the  motions  of  the  eyelids,  constantly  irritating  it.  keep 
it  from  healing,  and  greatly  augment  the  attending  ophthalmia. 
In  this  case,  there  is  one  method  of  treatment  which  is  eminently 
useful,  and  that  is  the  coating  of  the  ulcer  in  such  a  way,  that  it 
shall,  for  a  time  at  least,  become  insensible  to  the  irritations  in 
question.  This  is  effected  by  the  application  of  lunar  caustic,  either 
in  solution  or  in  substance.  This  kills  the  surface  of  the  ulcer, 
and  renders  it  able,  for  a  time,  to  withstand  the  friction  of  the  eye- 
lids and  the  influence  of  the  tears.  This  treatment  is  much  su- 
perior, as  an  anodyne,  to  any  sedative  lotion,  or  even  to  any 
narcotic  taken  internally.  In  the  interval  of  prevented  irritation, 
the  heahng  process  is  allowed  to  go  on,  and  before  the  thin  slough 
is  thrown  off,  which  is  formed  by  the  application  of  the  caustic, 
we  find  that  the  ulcer  has  contracted.  Were  we  to  leave  the  case 
here,  the  ulcer  would,  in  all  likelihood,  begin  again  to  spread  and 
to  penetrate  into  the  cornea.  As  soon,  then,  as  we  observe  that 
the  tears  are  producing  renewed  irritation,  and  the  ulcer  assuming 
a  new  degree  of  obscurity  and  irregularity,  the  caustic  must  be 
reapplied. 

In  cases  of  superficial  ulcer,  the  best  means  of  applying  the 
caustic  is  by  touching  the  diseased  surface  with  a  hair-pencil  dipped 
in  a  solution  of  from  2  to  4  grains  of  the  nitrate  of  silver  in  an 
ounce  of  distilled  water. 

The  deep  ulcer  is  better  managed,  in  general,  by  sharpening  a 
pencil  of  caustic,  and  touching  the  diseased  surface  with  it  for  an 
instant.  During  this  application,  the  upper  lid  is  to  be  kept  ele- 
vated by  Pellier's  speculum,  and  before  it  is  allowed  to  fall,  a  httle 
water  is  to  be  injected  over  the  cornea. 

The  caustic  is  to  be  applied  in  the  same  way  if  hernia  of  the 
cornea  be  present,  or  if  the  cornea  be  completely  penetrated,  and 
52 


410 

hernia  of  the  iris  has  taken  place.  In  fistula  of  the  cornea,  also, 
after  snipping  off  the  projecting  portion  of  conjunctiva,  the  opening 
is  to  be  touched  with  the  lunar  caustic  pencil.  When  the  hernia 
of  r[j8  cornea  or  of  the  ins  projects  much,  it  may  also  be  removed 
with  the  scissors,  and  then  the  caustic  applied.  The  contact  of 
the  caustic  is,  in  these  cases  also,  to  be  continued  only  for  an  instant. 
If  the  surface  of  the  ulcer,  or  the  piece  of  protruding  substance, 
be  just  whitened  by  the  action  of  the  nitras  argenti,  it  is  enough. 
We  ought  never  to  continue  the  contact,  so  as  to  cause  a  slough 
of  any  considerable  thickness. 

In  cases  of  deep  ulcer  over  the  pupil,  it  has  been  thought  advi- 
sable to  evacuate  the  aqueous  humour  near  the  edge  of  the  cornea, 
and  to  touch  the  ulcer  with  the  solution  of  lunar  caustic.  Dr. 
Monteath;  however,  has  recommended  a  different  practice. 

"  A  deep  scrofulous  ulcer  of  the  cornea,"  says  he,  "  nearly  pene- 
trating into  the  anterior  chamber,  at  which  stage  there  is  ahnost 
always  pretty  acute  inflammation,  assuming  the  vascular  character, 
is  very  apt  to  induce  iritis,  and  secretion  of  pus  into  the  anterior  cham- 
ber, forming  hypopion.  This  is  a  state  of  considerable  danger  to 
vision,  particularly  if  the  ulcer  be  nearly  opposite  to  the  pupil ;  but, 
wherever  it  may  be  situated,  I  hardly  ever  fail  to  excite  a  healing 
action  in  the  ulcer,  and  to  give  an  immediate  check  to  the  hypopion 
and  inflammation  of  the  iris,  by  the  following  treatment.  The 
iirsL  and  most  important  step,  is  to  perforate  the  remaining  layer,  or 
layers,  of  the  cornea,  at  the  JDOttom  of  the  ulcer,  with  an  iris-knife, 
and  allow  the  aqueous  humour  to  flow  out,  and  the  anterior  cham- 
ber to  collapse.  The  second,  is  to  give  a  full  dose  of  calomel  and 
opium  each  night,  till  the  mouth  is,  in  the  slightest  degree  affected. 
The  very  first  night  after  the  puncture,  the  patient  sleeps  soundly, 
which  he  had  been  prevented  from  doing  for  several  previous  nights 
by  violent  supra-orbital  and  hemicranial  pain.  In  a  day  or  two 
after  this  trifling  operation,  the  ulcer  is  completely  filled  with  co- 
agulable  lymph,  which  even  overlaps  its  border,  so  as  to  put  on  the 
appearance,  to  an  inexperienced  surgeon,  of  the  ulcer  being  much 
increased  in  size,  whereas,  it  is  the  most  favourable  circumstance 
that  could  happen,  because  the  redundant  lymph  is  removed  by 
absorption  in  a  very  few  days.  In  proportion  as  the  lymph,  de- 
posited in  the  ulcer,  becomes  organized,  the  integrity  and  natural 
size  of  the  anterior  chamber  are  restored.  From  the  combined  ef- 
fects of  the  evacuation  of  the  aqueous  humour,  and  of  the  mercury, 
the  iritis  is  rapidl}^  removed,  and  the  case  now  requires  merely  the 
ordinary  treatment  of  scrofulous  ophthalmia,  attended  with  an  ul- 
cer on  the  cornea,  which  is  one  of  the  most  common  occurrences  in 
ophthalmic  practice."  * 

I  regard  it  as  an  essential  part  of  the  treatment  in  all  cases  of 
deep  ulcer,  and  even  in  the  more  severe  cases  of  superficial  ulcer, 

*  Glasgow  Medical  Journal,  Vol.  ii.  p.  133.    Glasgow,  1829. 


411 

near  the  centre  of  the  cornea,  to  apply  belladonna,  so  as,  if  possible, 
to  dilate  the  pupil.  If  (his  is  neglected,  the  iris  may  readily  ad- 
vance into  contact  with  the  cornea,  even  when  the  ulcer  is  yet  far 
from  penetrating  into  the  anterior  chamber,  and  becoming  adherent, 
may  thus  give  rise  to  partial  staphyloma.  The  good  effects  of  bel- 
ladonna in  freeing  the  iris,  even  after  it  had  become  involved  in  an 
ulcer  of  the  cornea,  are  well  illustrated  by  the  case  of  James  Tassie, 
which  I  have  related  at  page  327.  In  cases,  however,  where  the 
iris  protrudes  to  one  side  of  the  cornea,  belladonna  appears  rather  to 
favour  a  farther  prolapsus,  and  ought,  therefore,  to  be  avoided, 
when  the  ulcer  is  not  over  the  pupil. 

Prognosis.  In  all  cases  of  deep  ulcer,  we  ought  to  forewarn 
the  patient  of  the  opacity  of  the  cicatrice,  and  the  consequent  de- 
formity, and,  it  may  be,  abridgement,  or  even  loss  of  sight.  Even 
when  the  ulcer  is  superficial,  it  is  proper  to  pronounce  a  dubious 
prognosis  ;  for,  though  the  conjunctiva  of  the  cornea  is  usually  re- 
generated, so  as  not  to  impair  the  cornea's  transparency,  this  is  by 
no  means  always  the  case. 


SECTION  IV. SPECKS  OR    OPACITIES  OF  THE    CORNEA 

NEBULA^ ALBUGO LEUCOMA. 

Specks  of  the  cornea  are  distinguished  by  different  names,  ac- 
cording to  the  degree  of  opacity  and  density  which  they  present, 
and  according  to  the  mode  of  their  formation. 

1.,  Nebula  is  the  slightest  degree.  It  resides  most  frequently  in 
the  conjunctival  layer  of  the  cornea ;  occasionally  it  has  its  seat  in 
the  lining  membrane  of  the  cornea ;  rarely  between  its  laminae. 
Nebula  is  supposed  to  be  sometimes  the  consequence  of  pressure 
merely,  from  preternatural  increase  of  the  aqueous  humour.  In 
some  cases  it  appears  to  be  the  result  of  serous  effusion  into  the 
substance  of  the  cornea  ;  in  others  to  arise  from  fibrine  deposited  in 
the  substance  either  of  the  lining  membrane  of  the  cornea,  or  of  its 
conjunctival  covering.  Nebula  includes  only  those  opacities  of  the 
cornea  which  are  cloudy  or  hazy.  This  kind  of  speck  is  usually 
also  extensive,  and  undefined,  becoming  less  and  less  opaque  towards 
its  edges,  and  often  affecting  the  whole  cornea. 

Nebula  is  a  frequent  consequence  of  puro-mucous  ophthalmia, 
but  the  most  common  cause  of  this  opacity  is  scrofulous  corneitis. 
The  inflammation  produced  by  inverted  or  supernumerary  eye- 
lashes, or  inverted  eyelids,  and  that  arising  from  sarcomatous  or 
granular  conjunctiva,  are  also  abundant  sources  of  nebula.  De- 
pending on  the  latter  causes,  this  opacity  will  require  for  its  removal, 
the  cure  of  the  disease  of  the  eyelid,  and  will  not  be  at  all  benefited 
by  any  remedies  directed  against  the  state  of  the  cornea  merely. 

2.  Whenever  the  effusion  of  lymph  into  any  part  of  the  cornea 
is  so  dense  as  to  present  a  pearly  or  chalk-whits  appearance,  the 
name  of  nebula  is  changed  for  that  of  albugo. 


412 

This  sort  of  speck  has  its  seat  most  frequently  under  the  con- 
junctiva of  the  cornea.  The  lymph  effused  forms  an  opaque  spot, 
generally  circular  or  oval,  more  dense  usually  in  the  centre  than 
towards  the  circumference,  but  in  some  rare  cases  presenting  the 
appearance  of  a  ring. 

The  common  source  of  albugo  is  a  phyctenula  or  pustule  on  the 
cornea,  which  has  receded  without  bursting.  Like  every  other 
abscess,  these  pimples  may  be  regarded  as  cavities  formed  by  the 
exudation  of  coagulable  lymph,  and  containing  pus.  The  sphere 
of  lymph  which  surrounds  the  pus  appears  to  be  formed  in  order  to 
limit  the  extent  of  the  disease.  When  the  pustle  disappears  with- 
out bursting,  the  contained  matter  being  absorbed,  the  sphere  of 
lymph  remains  for  a  time,  or  it  may  be,  continues  to  form  a  per- 
manent speck. 

Another  source  of  albugo  is  where  the  pus  of  an  onyx  is  either 
absorbed  or  evacuated  by  the  knife.  Onyx  or  abscess  of  the  cornea 
is  always  attended  by  more  or  less  lymphatic  effusion ;  and  after 
the  pus  is  dispersed,  the  laminse  of  the  cornea  which  w^ere  separated 
by  its  presence  are  reunited  by  the  process  of  adhesion,  which  can- 
not be  accomplished  without  a  new  secretion  of  lymph. 

Albugo  may  sometimes  be  observed  with  numerous  red  vessels 
running  into  it  from  the  conjunctiva,  and  is  extremely  apt,  when 
this  is  the  case,  to  spread  over  the  cornea.  This  vascular  albugo 
is  occasionally  very  obstinate.  It  is  somewhat  elevated  above  the 
level  of  the  cornea,  and  the  conjunctiva  corneae  through  which  the  red 
vessels  run  is  much  thickened.  In  some  cases,  these  vessels  are  so 
numerous,  as  to  make  the  albugo  appear  red,  with  patches  of  white 
in  the  interstices.  We  meet  with  this  variety  of  albugo  in  stru- 
mous adults,  and  sometimes  in  children.  The  shrinking  and  dis- 
appearance of  the  red  vessels  which  feed  it  afford  ground  to  believe 
that  the  albugo  will  cease  to  spread  ;  but  it  is  rarely  the  case  that 
the  speck  itself  totally  disappears. 

3.  A  third  sort  of  speck  is  called  leucom-a,  and  is  always  the  re- 
sult of  cicatrization.  A  loss  of  substance  in  the  cornea  by  ulcera- 
tion, and  a  partial  filling  up  of  that  loss  by  granulation,  always 
precedes  the  formation  of  leucoma,  which  indeed  is  synonymous 
with  opaque  cicatrice. 

Leucoma  may  in  general  be  known  by  its  contracted  and  cir- 
cumscribed appearance.  Albugo  is  more  diffused.  Leucoma  is 
often  flat,  and  is  frequently  combined  w4th  partial  adhesion  of  the 
iris  to  the  cornea. 

Prognosis  and  treatment.  All  the  three  kinds  of  speck,  nebu- 
la, albugo,  and  leucoma,  have  a  natural  tendency  to  disperse,  as 
soon  as  the  disease  upon  which  they  depend  begins  to  subside,  and 
that  whether  they  depend  on  primary  inflammation  spreading  to 
the  cornea,  or  secondary  inflammation  of  that  part  arising  from  the 
irritation  of  inverted  eyelashes  or  granular  conjunctiva.  We  must, 
then,  in  every  case  endeavour  to  remove  the  ophthalmia,  or  the 


413 

mechanical  irritation  on  which  the  opacity  depends,  assured  that 
if  we  succeed  in  this,  nature  by  the  process  of  absorption  will,  sooner 
or  later,  accomplish  the  whole  amount  of  recovery  whicli  is  possible. 
In  children  and  young  persons  many  very  dense  and  extensive  specks 
are  removed  in  the  natural  progress  of  the  growth  of  the  cornea, 
which  would  be  quite  immovable  in  adult  life. 

Demours  is  of  opinion  that  the  cornea  grows  from  its  circumfer- 
ence, and  relates,  in  support  of  this  idea,  the  case  of  a  child,  who, 
at  the^  age  of  six  months,  had  a  violent  inflammation  of  the  eye 
followed  by  abscess  of  the  cornea,  evacuation  of  the  aqueous  humour, 
and  adhesion  of  the  iris  to  the  cornea,  near  the  edge  of  the  scleroti- 
ca. At  the  age  of  eight  years,  this  adhesion  was  at  the  distance  of 
a  line  only  from  the  centre  of  the  cornea,  whence  it  follows  that  the 
growth  of  the  cornea  had  taken  place  between  the  adhesion  and  the 
edge  of  the  sclerotica.* 

We  are  able,  by  various  applications,  to  hasten  the  action  of  the 
absorbents  in  the  removal  of  specks,  especially  if  the  applications 
in  question  be  employed  at  the  proper  time.  If  we  commence  their 
use  too  soon,  that  is  to  say,  before  the  cause  of  the  opacity  be  sub- 
dued, we  shall  not  merely  torment  the  patient  unnecessarily,  but 
actually  impede  the  cure.  For  instance,  suppose  that  in  a  case  of 
albugo,  arising  from  scrofulous  corneitis,  and  still  attended  by  con- 
siderable vascularity,  the  practitioner  forthwith  began  to  attack  the 
opacity  of  the  cornea  with  stimulating  powders,  and  solutions  of 
irritating  or  caustic  substances,  not  only  would  he  fail  in  effecting 
his  object,  but  run  a  great  chance  of  rendering  his  patient  totally 
Wind.  But  if  he  began  by  attacking  the  strumous  inflammation 
which  still  hngered  in  the  eye,  aad  that  chiefly  by  constitutional 
remedies,  not  merely  would  he  witness  the  dispersion  of  the  redness, 
but  he  would  find  that  the  cornea  would  begin  to  clear,  and  that 
day  after  day,  a  little  more  of  the  effused  lymph  being  removed, 
the  patient's  vision  would  proportion  ably  improve. 

It  may  be  remarked  that,  in  general,  the  internal  and  constitu- 
tional remedies  which  do  good  in  cases  of  specks  of  the  cornea,  are 
those  which  operate  in  removing  the  ophtlialmiae  in  which  the 
opacities  have  originated  ;  and  the  same  observation  holds  good  in 
regard  to  the  local  remedies  also.  At  the  same  time,  there  are 
both  general  and  local  means  peculiarly  adapted  for  hastening  the 
absorption  of  opaque  depositions  in  the  cornea.  Mercuiy  is  a  gen- 
eral remedy  of  this  kind.  Some  opacities  yield  only  after  the  use 
of  country  air  and  generous  diet. 

When  we  find  that  the  process  of  clearing  has  begun  and  is 
going  on,  we  may  often  greatly  assist  it  by  such  local  nieans  as  the 
following  ;  a  solution  of  from  two  to  four  grains  of  lunar  caustic, 
three  or  four  grains  of  sulphate  of  zinc,  sulphate  or  ammoniaret  of 
fiopper,  or  from  one  to  two  grains  of  corrosive  sublimate  in  an  ounce 

*  Traite  des  Maladies  des  Yeux.    Tom.  i.  p.  54.     Paris,  1818. 


414 

of  distilled  water  ;  the  vinum  opii,  pure  or  diluted  ;  the  red  precipi- 
tate salve;  a  finely  levigated  powder,  consisting  of  one  drachm  of 
red  precipitate  and  an  ounce  of  white  sugar.  This  last  is  to  be 
blown  into  the  eye  through  a  quill ;  the  salve  is  to  be  introduced 
behind  the  upper  lid,  and  rubbed  into  the  cornea  by  moving  the 
lid  with  the  linger  in  various  directions  for  some  minutes ;  the  so- 
lutions may  either  be  dropped  in  by  means  of  a  camel-hair  pencil, 
or  injected  over  the  surface  of  the  eye  with  a  syringe.  One  only 
of  these  applications  is,  in  ordinary  cases,  used  daily  ;  but  when 
the  eye  is  less  sensitive  to  stimulants  than  common,  one  of  them 
may  be  applied  in  the  morning,  and  another  at  bedtime. 

The  solution  of  lunar  caustic  is  regarded  by  many  as  specific 
for  all  those  specks,  which  are  at  all  removable  by  excited  absorp- 
tion, so  that  they  keep  this  solution  ready  by  them  for  all  such 
cases.  It  will  be  found  advantageous,  however,  to  change  the 
stimulus,  after  it  has  been  continued  for  some  time. 

In  all  our  endeavours  to  remove  opacities  of  the  cornea,  it  is  ne- 
cessary to  bear  in  mind  that  the  points  of  importance  are  the  pe- 
riod of  the  disease  at  which  stimulants  are  hkely  to  prove  useful, 
and  the  regular  and  frequent  employment  of  the  stimulating  sub- 
stance or  substances  selected. 

There  are  few  cases  of  speck,  which  are  not  benefited  by  a  blis- 
ter kept  open  behind  the  ear,  or  on  the  back  of  the  neck,  and  by 
repeated  scarifications  of  the  conjunctiva  of  the  lids. 

I  have  generally  found  vascular  albugo  to  be  intractable,  unless 
the  vessels  running  into  the  speck  are  divided,  and  the  gums  af- 
fected by  the  administration  of  mercury.  The  best  mode  of  divid- 
ing the  fasciculus  of  vessels  is  to  lay  hold  of  a  fold  of  the  conjunc- 
tiva with  a  small  pair  of  hooked  forceps,  and  snip  it  off  with  the 
scissors.  If  the  enlarged  vessels  have  escaped  division  in  this  way, 
a  small  hook  may  now  be  easily  introduced  beneath  them,  so  as 
to  raise  them  within  grat;p  of  the  scissors.  Considerable  bleeding 
follows  this  operation,  and  ought  to  be  encouraged  by  warm  fomen- 
tations. 

The  vulgar  have  a  notion  that  specks  can  be  removed  by  opera- 
tion. This  is  impossible,  except  when  the  opacity  is  merely  a 
crust  of  oxide  or  carbonate  of  lead  deposited  on  the  surface  of  an 
ulcer  of  the  cornea,  in  consequence  of  a  solution  of  acetas  plumbi 
having  been  employed  as  a  collyrium.  It  sometimes  happens  that 
such  a  crust  remains  after  the  ulcer  is  cicatrized,  and  I  have  re- 
peatedly succeeded  in  lifting  it  away  with  a  sharp  end  of  a  probe, 
leaving  the  cornea  beneath  nebulous  merely,  and  susceptible  of 
clearing  completel}^  under  the  continued  application  of  vinum  opii. 


415 


SECTION  V. GRANULAR   CONJUNCTIVA.* 

In  treating  of  the  puro-mucous  ophthalmise,  I  have  repeatedly 
had  occasion  to  refer  to  the  thickened,  fleshy,  and  rough  state  of 
the  hning  membrane  of  the  lids,  and  especially  of  the  upper  lid, 
which  is  known  by  the  name  oi  granular  conjunctiva.  At  page 
287,  I  have  made  some  remarks  on  the  sense  in  which  the  term, 
granular  is  here  to  be  taken,  and  on  the  impropriety  of  calling 
the  prominences  of  the  conjunctiva  which  exist  in  this  disease, 
gra7iulatio7is.  I  have  stated,  also,  that  I  consider  the  prominen- 
ces in  question  to  be  principally  the  acini  of  the  Meibomian  follicles 
in  a  state  of  enlargement.  This  conclusion  I  have  come  to,  not 
merely  from  the  seat  of  this  affection,  w^iich  is  chiefly  the  internal 
surface  of  the  upper  hd,  where  these  follicles  are  most  abundant, 
but  from  what  1  have  observed  on  drying  portions  of  granular  con- 
junctiva which  I  had  removed  with  the  scissors.  In  such  portions, 
I  have  distinctly  perceived  the  acini  of  the  Meibomian  follicles. 

The  conjunctiva  in  the  indurated  and  granular  state,  which  is 
so  apt  to  continue  as  a  sequela  of  the  puro-mucous  ophthalmise, 
rubbing  against  the  cornea,  keeps  this  part  in  a  state  of  constant 
irritation,  so  that  it  becomes  vascular  and  nebulous,  particularly  in 
its  upper  half.  Should  the  case  be  neglected,  great  thickening, 
with  roughness,  and  total  opacity  of  the  cornea,  may  at  length  be 
the  result. 

Prognosis.  Although  by  sufficient  clothing,  proper  diet,  re- 
striction from  intemperance,  good  air.  and  judicious  medical  treat- 
ment, the  granular  state  of  the  lids,  and  opacity  of  the  cornea, 
may  be  removed,  and  vision  restored  ;  yet,  if  the  patient  be  guilty 
of  intemperance,  or  be  insufiicienlly  protected  from  cold  winds,  or 
damp  cold  weather,  a  relapse  will  almost  certainly  take  place,  at- 
tended by  renewed  inflammation  of  the  conjunctiva  and  puriform 
discharge.  Frequent  relapses  may  at  last  render  this  disease  in- 
curable. 

Treatment.  The  treatment  which  I  have  found  most  success- 
ful consists  in  scarification  of  the  conjunctiva,  the  application  of 
escharotics,  and  the  use  of  counter-irritation. 

The  eyelids  being  everted,  so  as  completely  to  expose  their  in- 
ternal surface,  the  scarification  is  to  be  conducted  as  has  been  stated 
at  page  267. 

Next  day,  or  two  or  more  days  after  the  scarification,  according 
to  circumstances,  the  lids  being  again  everted  as  before,  and  dried 
from  any  of  the  gleety  mucus  with  which  they  may  be  covered, 
the  lunar  caustic  pencil  is  to  be  brought  into  a  single  rapid  contact 
with  the  prominences  which  we  wish  to  remove.  Before  allowing 
the  Uds  to  be  replaced,  a  little  warm  water  may  be  squirted  over 

"*  Trachoma ;  Pladarotes. — Hie  afFectus  etiam  sycosis  seu  palpebra  Jicosa  dicitur, 
quia  interna  palpebra  superficies  ficus  discissi  adinstar  granulosa  evadit.  Plenck  de 
Morbis  Oculorum,  p.  30.    Vienna,  1777. 


416 

the  surface  which  has  been  touched  with  the  caustic.  It  is  advan- 
tageous after  a  time  to  change  the  lunar  caustic  for  the  sulphate 
of  copper,  which  may  be  more  hberally  apphed.  The  scarification 
and  the  caustic  are  to  be  employed  alternately  at  intervals  of  two 
or  three  days. 

Escharotics  and  stimulants  in  solution,  or  in  ointment,  are  also 
useful ;  as,  the  lunar  caustic  solution,  the  expressed  juice  of  the 
root  of  the  holcus  avenaceus,  the  red  precipitate  salve,  &c.  These 
assist  in  trlearing  the  cornea,  as  well  as  repressing  the  sarcoma  of 
the  conjunctiva. 

During  the  employment  of  these  remedies,  a  blister  is  to  be  kept 
open  on  the  nape  of  the  neck. 

By  continuing  this  plan  of  treatment  with  regularity  for  some 
weeks,  I  have  often  succeeded  in  removing  granular  conjunctiva 
after  it  had  resisted  a  variety  of  other  less  methodical  modes  of 
treatment.  The  cure  will  be  greatly  promoted  by  attention  to  the 
dietetical  adjuvants  mentioned  under  the  head  of  the  prognosis. 

When  tliis  state  of  the  conjunctiva  has  proceeded  to  a  very  great 
degree  of  exuberance,  and  continued  for  many  months,  notwith- 
standing a  careful  trial  of  the  plan  of  treatment  now  explained,  it 
may  be  necessar}"  to  have  recourse  to  a  more  speedy  and  effectual 
method  of  removal,  namely,  by  the  knife.*  The  eyelid  to  be  ope- 
rated on  is  to  be  evened  as  completely  as  possible,  a  small  and  very 
sharp  lancet-shaped  knife  is  to  be  laid  flat  at  the  root  of  this  layer 
of  indurated  conjunctiva,  which  is  then  to  be  pared  off  by  a  steady 
motion  of  the  instrument  onwards,  sawing  as  little  as  possible. 

In  performing  this  operation,  which  is  generally  attended  by  very 
considerable  pain,  it  is  necessary  to  beware  of  removing  more  than 
the  mere  layer  of  indurated  conjunctiva.  If  more  than  this  is  taken 
away,  hard  and  irregular  cicatrices  are  left  on  the  internal  surface 
of  the  lids,  the  effects  of  which  on  the  corneee  are  scarcely,  if  at  all, 
less  prejudicial  than  those  of  the  disease  which  has  been  removed. 


SECTION  VI. ANCHYLO-BLEPHARON  AND  SYM-BLEPHARON. 

A  union  of  the  edges  of  the  eyelids  or  anchylo-hlepharon,  and 
a  union  of  the  eyelids  to  the  globe  of  the  eye  or  sym-hlepharon, 
are  two  diseased  states  which  may  occur  either  separately  or  to- 
gether. 

The  edges  of  the  lids  may  unite  in  (heir  whole  length,  or  only 
in  part  of  their  extent,  and  that  generally  at  their  temporal  extrem- 
ity. There  is  always  more  or  less  of  an  opening  at  their  nasal 
angle.  Sym-blepharon  may  also  be  complete  or  incomplete  ;  the 
conjunctiva  of  the  eyeball  being  united  with  the  whole  conjunctiva 
of  one  or  of  both  eyelids,  or  a  similar  connexion  existing  only  in  a 
small  extent.  These  modifications  have  considerable  influence  upon 
the  prognosis  and  method  of  cure  ;  less,  however,  than  the  following. 

"  Sir  William  Read's  Short  but  Exact  Account  of  all  the  Diseases  incident  to  the 
Eyes,  page  96.    London,  1706. 


4\1 

It  sometimes  happens  that  the  injured  edges  of  the  eyeUds,  or 
the  surfaces  of  the  excoriated  or  ulcerated  conjunctiva,  being  left 
for  a  time  in  immediate  and  constant  apposition,  a  close  and  inti- 
mate union  takes  place,  Much  more  frequently,  however,  a  con- 
siderable quantity  of  coagulabl6  lymph  is  effused  between  the  two 
edges,  or  between  the  two  surfaces,  and  becoming  organized  forms 
the  bond  of  these  morbid  connexions.  When  the  lids  are  united 
in  this  manner,  we  find  a  whitish,  uninterrupted,  firm  membrane, 
occupying  and  obliterating  their  natural  opening ;  and  when  the 
eyeball  is  united  to  one  or  both  lids  in  this  way,  the  organized 
coagulable  lymph  which  forms  the  union,  presents  itself  in  bundles 
of  an  almost  tendinous  texture,  stretching  from  the  one  part  to  the 
other.  These  bundles  may  be  compared  in  some  respects  to  those 
partial  adhesions  which  are  so  frequently  met  with  between  the 
pleura  which  covers  the  lungs  and  that  which  lines  the  ribs ;  but 
in  one  respect  they  are  essentially  different,  namely,  that  as  the 
pleura  is  a  serous  membrane,  these  adhesions  in  the  thorax  may 
take  place  upon  the  slightest  inflammation,  whereas  the  conjunctiva, 
following  the  laws  to  which  all  other  mucous  membranes  are  sub- 
ject, will  never  adhere  in  the  manner  described,  so  long  as  it  con- 
tinues entire.  Were  mucous  membranes  under  the  same  law  as 
serous  membranes  in  this  respect,  the  dangers  to  which  life  is  ex- 
posed would  be  greatly  increased,  as  adhesions  between  the  oppo- 
site sides  of  all  the  hollow  viscera  would  be  continually  taking 
place.  Nature  has  therefore  wisely  provided  that  no  mucous  mem- 
brane can  become  adherent,  so  long  as  its  surface  continues  entire ; 
and  accordingly  we  find  that  till  it  is  wounded,  or  till  it  becomes 
excoriated  or  ulcerated,  the  conjunctiva  of  the  eyeball  never  con- 
tracts adhesions  to  that  of  the  eyelids.  Indeed,  ulceration  of  the 
cornea  precedes  almost  every  case  of  sym-blepharon. 

Causes.  The  causes  of  anchylo-blepharon  and  sym-blepharon 
are  to  be  found  chiefly  in  such  traumatic  inflammations  as  arise 
from  burns,  or  from  the  influence  of  escharotics ;  although  any 
other  ophthalmia,  productive  of  excoriation  or  ulceration  of  the 
edges  of  the  eyehds  or  of  the  conjunctiva,  may  give  rise  to  these 
consequences.  They  occur  most  frequently  in  those  whose  eyes 
have  been  injured  by  boihng  fluids,  concentrated  acids,  or  quick- 
lime, and  in  those  who,  labouring  for  a  great  length  of  time  under 
puro-mucous  ophthalmia,  and  being  unable  to  withstand  the  hght, 
or  to  procure  medical  assistance,  have  lain  buried  for  weeks  in  some 
dark  corner  with  their  eyelids  constantly  closed. 

Prognosis.  The  prognosis  is  extremely  various,  and  depends 
upon  the  possibihty  of  completely  separating  the  morbid  adhesion?, 
the  chance  of  preventing  them  from  returning,  and  the  advantage 
the  patient  is  hkely  to  gain  if  they  were  removed. 

The  operation  for  anchylo-blepharon  can  be  performed  with  a 
reasonable  hope  of  success,  only  when  the  union  of  the  edges  of 
the  eyelids  is  not  complicated  with  union  between  the  eyeball  and 
53 


418 

the  eyelids  ;  or  if  the  latter  union  be  present,  when  it  is  inconsid- 
erable in  extent,  and  does  not  involve  the  cornea.  There  are 
various  means  for  ascertaining  the  facts.  One  is  to  take  hold  of 
a  fold  of  the  upper  eyelid,  and  drawing  it  from  the  eyeball,  desire 
the  patient  to  move  about  the  eye  as  much  as  he  can.  By  this 
means  we  shall  not  merely  discover  the  existence,  but  ascertain 
prci/.y  coriectl}^  the  extent,  of  any  adhesion  between  the  eyeball 
and  eyelids.  A  second  means  is  the  introduction  of  a  small  probe 
at  the  nasal  angle  of  the  lids.  If  there  be  no  sym-blepharon,  the 
probe  passes  on  with  ease  to  the  temporal  angle,  whereas  when 
adhesion  exists,  we  ascertain  its  situation  and  extent  by  the  oppo- 
sition which  it  gives  to  the  point  of  the  instrument.  A  good  deal 
may  be  ascertained  also,  by  observing  the  degree  of  sensibihty  to 
light  which  remains.  If  the  patient,  with  the  lids  in  the  state  of 
anchylo-blepharon  be  able  to  distinguish  all  the  gradations  of  light^ 
the  adhesion  does  not  involve  the  cornea,  which  to  a  certainty  re- 
mains transparent.  If  he  distinguishes  only  the  more  considerable 
changes  of  light,  while  the  slighter  gradations  escape  him,  we  must 
operate  in  a  degree  of  uncertainty  regarding  the  state  of  the  cornea. 
Perhaps  it  may  not  be  adherent,  but  probably  it  is  in  some  mea~ 
sure  opaque.  If  there  is  no  sensibility  to  light,  we  may  conclude 
either  that  the  adhesion  extends  to  the  whoL  surface  of  the  cornea, 
and  probably  includes  even  a  considerable  portion  more  of  the  sur- 
face of  the  eyeball,  or  at  least  that  the  cornea,  by  the  same  inflam- 
mation which  produced  the  anchylo-blepharon,  has  been  rendered 
completely  opaque,  and  that  therefore  the  great  object  of  an  ope- 
ration cannot  be  obtained,  namely,  the  restoration  of  sight. 

We  will;  of  course,  recommend  the  patient  to  undergo  an  ope- 
ration, when  the  case  appears  to  be  a  simple  anchylo-blepharon  \ 
when  there  appears  to  be  not  only  no  sym-blepharon  present,  but 
when  we  judge  that  the  surface  of  the  eyeball  has  either  not  suf- 
fered at  all,  or  suffered  but  httle,  from  the  inflammation  in  which 
the  anchylo-blepharon  has  originated.  On  the  contrary,  when  the 
sensibility  to  light  is  extremely  indistinct  or  altogether  wanting,  or, 
even  though  the  sensibilit}'  to  light  be  pretty  distinct,  if  the  eyeball 
feels  to  the  finger,  through  the  eyelid,  larger  or  smaller,  harder 
or  softer,  or  quite  irregular  on  its  surface,  we  will  be  cautious  in 
recommending  any  operation,  as  the  patient  would  thank  us  but 
little  if  we  jnerely  brought  into  view  a  useless  and  destroyed  eye 
which  had  formerly  been  concealed. 

There  is  one  reason,  however,  which  may  sometimes  lead  us  to 
operate  for  sym-blepharon,  altogether  independent  of  any"  hope  of 
restoring  sight.  If  the  one  eye  is  sound,  and  the  other  affected  with 
this  moibid  union,  the  patient  on  at'empting  to  look  from  side  to 
side,  experiences  a  disagreeable  or  even  painful  feehng  of  dragging 
in  th'=  ey 3  affected  \vith  sym-blepharon  which  restrains,  in  some 
measure,  the  exercise  even  of  the  sound  eye.  To  relieve  this,  and 
with  no  view  of  restoring  the  sight,  I  have  been  solicited  to  separate 
the  eyeball  from  morbid  connexions  with  the  eyehds. 


419 

It  sometimes  happens  that  we  meet  with  sym-blepharon  combined 
witli  staphyloma,  and  here  also  we  may  be  obHged  to  operate  with- 
out any  reference  to  restoration  of  vision,  which  in  such  circum- 
stances is  entirely  out  of  the  ques<^\on.  The  hds,  bound  down  tothe 
cornea,  resist  the  grov^^ing  staphyloma,  and  thereby  cause  a  great 
degree  of  pain,  which  we  are  sometiuies  led  to  I'elieve  for  a  time  by 
puncturing  the  eye;  but  the  puncture  soon  closes,  the  staphyloma 
again  presses  against  the  lids,  the  pain  and  fever  return,  and  lO  give 
permanent  relief,  we  are  forced,  first,  to  operate  for  the  sym-biepha- 
roa,  and  immediately  after  to  remove  the  staphyloma. 

Treatment.  The  operation  for  anchylo-blepharon  requires  to  be 
performed  somewhat  differently,  according  as  the  eyelids  are  united 
immediately,  or  through  the  medium  of  a  pseudo-membrane.  If 
they  are  united  immediately,  the  assistant  takes  hold  of  the  upper 
lid  between  his  finger  and  thumb,  so  as  to  form  a  perpendicular 
fold,  which  he  raises  as  much  as  possible  from  the  eyeball,  while 
the  operator,  with  his  left  hand,  does  the  same  to  the  lower  lid. 
With  a  scalpel  the  operator  now  divides  the  fold,  which  is  thus  form- 
ed, by  a  transverse  incision,  three  or  four  lines  long,  exactly  in  the 
course  of  the  natural  opening  of  the  lids.  Through  the  incision 
thus  made,  a  small  grooved  director  is  to  be  passed  and  run  along 
to  the  nasal  angle  of  the  lids,  which  is  almost  always  open,  and 
where  the  extremity  of  the  director  will  appear.  The  incision  is 
now  continued  to  the  inner  canthus,  and  then  to  the  outer.  After 
the  central  opening  is  made  in  the  manner  described,  the  rest  of  the 
operation  may  be  performed  with  scissors,  with  which  instrument, 
the  separation  at  the  temporal  angle  of  the  lids,  v.nll  always  be  most 
easily  effected. 

When  the  union  of  the  edges  of  the  lids  is  through  the  medium 
of  a  pseudo-membrane,  we  perform,  first  of  all,  an  operation  similar 
to  the  above,  only  that  we  make  the  incision  close  to  the  edge  of 
the  upper  eyelid,  leaving  the  whole  of  the  pseudo-membrane  at- 
tached to  the  lower  eyelid.  Then  laying  hold  of  the  membrane 
with  a  pair  of  forceps,  we  remove  it  completely  with  the  scissors. 

This  may  appear  a  very  precise  sort  of  operation  ;  but  the  pre- 
cision of  the  operation  is  nothing,  compared  with  that  which  it 
is  necessary  to  observe  in  the  after-treatment.  Our  care  may  be 
said  to  commence  at  the  moment  when  the  operation  is  finished, 
for  its  success  depends  entirely  upon  our  preventing  the  reunion  of 
the  separated  lids,  or,  in  other  words,  upon  their  edges  becoming 
quickly  skinned  over,  without  much  inflammation  or  suppuration. 
If  this  does  not  take  place  they  unite  again,  either  immediately, 
or  by  a  new  pseudo-membrane.  In  order  to  prevent  this,  we 
ought  to  perform  the  operation  pretty  early  in  the  morning,  after  the 
patient  has  had  a  good  night's  rest,  in  order  that  he  may  be  able 
to  remain  the  longer  without  sleep  after  the  operation,  and  thus 
any  long-continued  approximation  of  the  eyehds  be  prevented.  The 
edges  ought  to  be  alternately  washed  with  a  tepid  coUyrium  of  ace- 


420 

tate  of  lead  in  rose-water,  and  besmeared  with  tutty  ointment.  An 
assistant  should  sit  by  the  patient  during  the  first  night  after  the 
operation,  and  frequently  repeat  these  applications.  With  all  this 
care,  some  re-adhesion  is  still  apt  to  form  in  the  temporal  angle,  to 
prevent  which,  the  patient  should  be  awakened  repeatedly  during 
the  night;  and  made  to  open  his  eyes  as  widely  as  he  can,  and  this 
he  should  also  do  frequently  in  the  course  of  the  day. 

When  a  case  of  sym-blepharon  presents  itself,  it  is  not  difficult  to 
determine  whether  we  can  undertake  an  operation  with  hopes  of 
success.  We  see  distinctly  in  what  condition  the  cornea  is,  and  can 
judge  what  will  be  the  effects  of  dividing  the  morbid  adhesions. 

If  the  union  be  immediate,  the  assistant  draws  the  upper  eyelid 
upwards,  and  from  the  eyeball  as  much  as  possible,  while  the  ope- 
rator draws  the  lower  eyelid  downwards,  in  order  that  the  whole  ex- 
tent of  the  united  places  being  brought  into  view,  and  put  on  the 
stretch,  they  may  be  the  more  easily  and  accurately  divided.  This 
is  to  be  accomplished  with  a  small  scalpel.  The  external  edge  of 
the  union  is  always  the  firmest  part,  the  interior  parts  being  much 
looser.  During  the  separation,  we  must  carefully  avoid  injuring 
thd  cartilages  of  the  eyelids  on  the  one  hand,  and  the  sclerotica  and 
cornea  on  the  other. 

If  the  sym-blepharon  exists  through  the  medium  of  bundles  of 
organized  coagulable  lymph,  after  putting  the  conjunctiva  on  the 
stretch  as  in  the  last  case,  we  must  endeavour  to  cut  away  the  bands 
as  close  to  the  conjunctiva  of  the  eyelids  as  possible,  and  then  lay- 
ing hold  of  them  with  a  pau'  of  hooked  forceps,  dissect  them  cau- 
tiously from  the  eyeball. 

All  that  has  been  said  respecting  the  habihty  of  anchylo-ble- 
pharon  to  recur  after  the  operation,  is  applicable  to  the  present  case, 
only  that  here  it  seems  almost  impossible  by  any  contrivance  to 
prevent  the  contact  of  the  two  raw  surfaces.  One  of  my  pupils 
suggested  to  me  an  artificial  eye,  as  the  substance  most  likely  to 
answer  the  purpose  of  preventing  reunion.  I  am  afraid,  however, 
that  not  even  this  could  be  borne,  and  that  we  must  trust  to  the 
use  of  the  coUyrium  and  ointment  above  mentioned,  and  to  very 
frequent  motion  of  the  eye.  We  need  never  think  of  performing 
the  operation  for  sym-blepharon  without  the  formation  of  some  new 
bands  of  coagulable  lymph,  which  will  require  to  be  removed  by  a 
second  operation.  Celsus  honestly  confesses,  that  he  never  saw 
any  one  cured  by  the  operation  ;  and  states  that  Meges,  who  had 
tried  it  many  times,  avowed  that  he  had  never  succeeded,  but 
that  the  eyehd  had  constantly  become  again  adherent  to  the  eye- 
baU." 

*  De  Re  Medica ;  Lib.  viL  Cap.  1.  Sect.  2. 


421 


SECTION  VII. SYNECHIA. 


The  term  synechia  is  employed  to  signify  any  moibid  adhesion 
of  the  iris.  When  the  adhesion  is  to  the  cornea,  it  is  termed  syne- 
chia atiterior  ;  when  to  the  capsule  of  the  crystalline  lens,  syne- 
chia posterior.  The  former  is  the  result  of  a  penetrating  wound 
of  the  cornea,  or  of  severe  inflammation  of  that  part,  generally  in- 
deed of  ulcerative  inflammation,  ending  in  perforation  into  the  an- 
terior chamber,  and  escape  of  the  aqueous  humour.  The  latter  is 
the  frequent  consequence  of  iritis. 

It  is  the  dread  of  such  results  which  makes  us  anxious  in  the 
treatment  of  the  ophthalmia,  knowing  that  once  formed,  these 
morbid  adhesions  can  scarcely  ever  be  separated.  In  some  in- 
stances of  partial  synechia  anterior,  and  of  synechia  posterior  even 
when  complete,  which  last  is  almost  always  attended  by  closure  of 
the  pupil,  vision  may  be  restored  by  the  formation  of  an  artificial 
pupil. 


SECTION  VIII. OBLITERATION  OF  THE  PUPIL. 

It  has  been  fully  explained  in  the  sixteenth  and  following  sections 
of  the  last  chapter,  that  in  consequence  of  inflammation  of  the  iris, 
the  pupil  is  apt  to  become  narrowed,  misshapen,  fixed,  and  filled 
with  coagulable  lymph,  a  state  of  the  parts  to  which  the  terms 
atresia]  iridis,  and  synizesis^X  have  been  applied. 

No  operation  can  open  up  the  natural  pupil,  but  in  many 
cases  of  this  sort  an  artificial  pupil  may  be  formed  with  advan- 
tage. 

The  use  of  belladonna  in  cases  of  closure  of  the  pupil  ought  not 
to  be  hastily  abandoned.  The  filtered  aqueous  solution,  dropped 
upon  the  conjunctiva  every  second  day,  and  continued  for  several 
months,  is  often  followed  by  some  degree  of  dilatation,  and  consid- 
erable improvement  in  vision. 


SECTION    IX. CATARACTS    OR    SPECKS    OF    THE    CRYSTALLINE 

CAPSULE  AND  LENS. 

The  origin  of  these  sequelae  of  ophthalmia  has  been  fully  explained 
in  those  sections  of  the  last  chapter,  which  treat  of  iritis,  and  in- 
flammation of  the  crystalline  lens  and  capsule.  When  once  fair- 
ly confirmed,  no  means  of  cure  are  of  any  avail,  except  the  removal 
of  the  opaque  body  by  an  operation. 

*  2uvf;tH*,  continuity. 

t  From  a.  negative,  and  "r/Testa,  to  perforate. 

t  ^uvt^Ho-ii)  a  running  together. 


422 


SECTION  X. DISSOLUTION  OF  THE  VITREOUS  HUMOUR. 

This  has  been  styled  synchesis,*  and  is  in  fact  a  disorganization 
and  solution  of  the  hyaloid  membrane.  It  is  totally  incurable,  and 
sooner  or  later  is  accompanied  by  amaurosis.  It  remains  to  be  as- 
certained by  dissection,  whether  the  boggy  state  of  the  eyeball,  re- 
ferred to  at  page  374,  depends  on  dissolution  of  the  hyaloid  mem- 
brane, or  merely  diminution  of  its  contents.  When  the  vitreous 
capsule  is  dissolved,  it  by  no  means  necessarily  follows  that  the  eye 
should  feel  soft  or  boggy.  On  the  contrary,  it  often  feels  harder 
than  natural,  owing  probably  to  a  superabundant  quantity  of  aque- 
ous fluid,  occupying  the  place  of  the  vitreous  humour. 


SECTION  XI. — ATROPHY  OF  THE  EYE. 

Severe  ophthalmise,  and  especially  severe  internal  ophthalmiae, 
excited  by  injuries  in  strumous  subjects,  are  apt  to  be  followed  by 
an  absorption  of  the  contents  of  the  eyeball,  and  shrinking  of  its 
coats.  When  it  goes  to  a  great  length,  this  state  is  termed  phthisis 
oculi.  In  all  degrees  of  atrophy  of  the  eye,  the  prognosis  is  unfa- 
vourable. Operations  upon  eyes  which  have  shrunk  to  less  than 
their  natural  size  are  rarely  attended  with  any  success. 


SECTION  XII. STAPHYLOMA. 

Various  protrusions  from  the  front  of  the  eye  have  received  the 
name  of  staphyloma,  from  the  resemblance  which  they  occasionally 
bear  to  a  grape.t 

1.  Staphyloma  of  the  Iris,  or  Staphyloma  racemosum.X 

It  sometimes  happens  that  the  cornea  is  perforated  by  ulceration, 
not  in  one  point  alone,  but  in  many,  and  that  through  the  open- 
ings thus  formed,  the  iris  protruding  gives  rise  to  an  appearance 
somewhat  like  a  cluster  of  berries.  These  protrusions  continue  of 
a  dark  colour,  and  are  scarcely  covered  by  any  pseudo-cornea.  One 
or  more  of  them  occasionally  become  very  thin,  give  way,  and 
allow  the  aqueous  humour  to  escape.  The  staphyloma  conse- 
quently becomes  flat,  and  sometimes  disappears  altogether,  the  cor- 
nea cicatrizing  over  the  seat  of  the  former  protrusion.  In  other 
cases  the  staphyloma  of  the  iris  degenerates  into  staphyloma  of  the 
cornea  and  iris. 

Prognosis  and  Treatment.  If  any  considerable  portion  of  the 
cornea  be  in  a  natural  state,  it  may  be  possible  to  form  an  artificial 
pupil  behind  that  portion,  after  the  staphyloma  of  the  iris  is  re- 

*  'Xuy^va-ti,  confusion.  +  Srst^xx,  a  grape, 

t  From  raceTTMs,  a  bunch  of  grapes  or  berries. 


423 

moved,  which  is  sometimes  effected  by  puncturing  the  individual 
protrusions  with  the  point  of  a  cataract-needle,  and  touching  them 
with  the  lunar  caustic  pencil.  If  more  considerable,  they  may  be 
snipped  off,  and  the  place  touched  in  the  same  way.  When  the 
whole  cornea  is  affected,  nothing  can  restore  vision.  The  staphy- 
loma may  be  punctured  occasionally,  or  removed  entirely  by  the 
knife,  exactly  as  a  total  staphyloma  of  the  cornea  and  iris  is  re- 
moved, which  will  be  followed  by  a  flat  and  opaque  pseudo-cornea^ 
adherent  to  the  capsule  of  the  lens. 

2.  StaphyloTna  of  the  Cornea  and  Iris 

Is  styled  partial  or  total,  according  as  it  involves  a  portion  only, 
or  the  whole  of  these  parts.  The  most  evident  symptoms  are 
opacity  and  projection  of  the  cornea,  but  an  essential  part  of  the 
disease  is  adhesion  of  the  iris  to  the  portion  of  the  cornea  which  is 
affected,  and  consequently  diminution  or  total  obhteration  of  the 
anterior  chamber. 

It  has  been  maintained  by  some,  that  the  secreting  organ  of  the 
aqueous  humoiu'  resides  principally,  if  not  entirely,  in  the  posterior 
chamber,  while  the  absorbing  organ  of  that  fluid  resides  in  the  an- 
terior chamber.*  I  do  not  regard  this  as  a  point  which  is  estab- 
lished, but  I  must  confess  that  the  phenomena  Avhich  attend  the 
disease  now  under  consideration  go  a  considerable  way  in  its  sup- 
port. In  staphyloma  of  the  iris  and  cornea,  the  anterior  surface  of 
the  former  is  either  partially  or  throughout  its  whole  extent  glued 
by  adhesive  inflammation  to  the  posterior  surface  of  the  latter,  so 
that  the  anterior  chamber  is  abridged  or  annihilated,  and  the  func- 
tions of  the  membrane  which  lines  that  cavity  proportionally  inter- 
rupted. The  posterior  chamber,  on  the  other  hand,  remains  in 
most  cases  entire,  the  functions  of  its  lining  membrane  are,  so  far 
as  we  know,  left  unimpaired,  and  if  this  membrane  possessed  in  an 
equal  degree  both  a  secreting  and  an  absorbing  power,  the  quan- 
tity of  aqueous  humour  ought  to  continue  the  same.  This  is  not 
the  case.  Much  more  aqueous  humour  is  secreted  than  is  ab- 
sorbed, and  the  consequence  is  the  formation  and  constant  enlarge- 
ment of  that  projection  of  the  united  cornea  and  iris,  to  which  w© 
give  the  name  of  staphyloma. 

It  is  remarkable  that  when  the  cornea  merely  gives  way  by  ul- 
ceration, and  then  cicatrizes,  forming  a  leuconja,  this  cicatrice  i& 
sufficiently  strong  to  resist  the  pressure  of  the  aqueous  humour  ;  but 
when,  in  addition  to  the  leucoma,  there  is  extensive  adhesion  be- 
tween the  iris  and  the  internal  surface  of  the  cornea,  these  parts  in 
union  are  insufficient  to  resist  that  pressure,  and  are  projected  by  it 
into  a  staphyloma.  This  fact  seems  explicable  only  upon  the  sup- 
position above  mentioned,  that  the  absorption  of  the  aqueous  hu- 

*•  Memoire  sur  les  Proces  Ciliaires,  par  F.  Ribes ;  Memores  de  la  Societe  Medi- 
cate d'Emulation.     Tome  viii.  p.  859.    Paris,  1817, 


424 

mour  is  carried  on  chiefly  in  the  anterior  chamber,  while  its  secre* 
tion  goes  on  principally  in  the  posterior ;  and  that  as  by  the  union 
of  the  iris  to  the  cornea,  the  absorption  must  be  impeded,  while  the 
secretion  continues  as  in  health,  the  quantity  is  superabundant  in 
relation  to  the  cavities  in  which  it  is  deposited,  and  must  therefore 
tend  to  dilate  them  at  such  part  of  their  parietes  as  is  weakened  by 
disease.  The  dilatation  occasionally  goes  on  to  a  very  great  ex- 
tent, so  that  the  staphyloma  becomes  excessively  thin,  and  at  last 
gives  way  :  in  which  case  the  aqueous  humour  escapes,  and  the 
tumour  for  a  time  subsides,  but  on  the  rupture  healing,  it  gradually 
returns  to  its  former  size. 

Causes.  Onyx,  hypopium,  and  ulceration  of  the  cornea  are 
precursors  in  almost  all  cases  of  staphyloma.  Small-pox  pustules 
on  the  cornea  being  extremely  apt  to  end  in  bursting  of  the  cornea 
and  adhesion  of  the  iris,  staphyloma  was  a  much  more  frequent  oc- 
currence before  the  general  introduction  of  vaccination  than  it  is  at 
present.  Tlie  ophthalmia  of  new-born  children,  the  contagious  or 
Egyptian  ophthalmia,  and  severe  strumous  ophthalmia,  are  the 
common  causes  of  staphyloma  at  the  present  day. 

1.  Partial  staphyloma,  being  generally  the  result  of  an  onyx, 
occupies,  in  nine  cases  out  of  ten,  the  lower  part  of  the  cornea. 

In  those  cases  where  it  does  not  cover  nor  involve  the  pupil,  the 
patient  is  able  to  see  with  more  or  less  distinctness  those  objects 
which  are  placed  above  him  or  on  a  level  with  his  eye,  but  he  is 
generally  affected  with  epiphora,  and  painful  sensibility  of  the  or- 
gan. In  more  unfortunate  cases  of  staphyloma,  the  whole  edge  of 
the  pupil  is  adherent  to  the  opaque  and  projecting  portion  of  the 
cornea,  and  the  patient  can  recover  a  degree  of  vision  only  by  the 
formation  of  a  lateral  artificial  pupil. 

Partial  staphyloma  is  sometimes  confounded  with  leucoma,  al- 
though by  a  careful  examination  of  the  eye  this  mistake  may  al- 
ways be  avoided.  To  the  whole  extent  of  the  partial  staphyloma 
the  iris  is  firmly  adherent,  so  that  the  anterior  chamber  is  much 
diminished  in  size ;  whereas,  in  leucoma,  the  iris  is  either  not  at 
all  adherent  to  the  cornea,  or  adheres  to  it  in  a  mere  point.  In 
partial  staphyloma,  the  whole  cornea  partakes  in  some  measure  in 
a  conical  form,  the  termination  of  the  cone  being  at  the  centre  of 
the  staphyloma ;  whereas  in  leucoma,  the  general  spherical  form 
of  the  cornea  remains  unaltered,  the  leucoma  being  scarcely  percep- 
tibly raised  above  the  level  of  the  rest  of  the  cornea,  and  not  unfre- 
quently  depreesed. 

The  very  considerable  degree  of  vision  which  patients  with  par- 
tial staphyloma  often  possess,  may  readily  be  lost,  either  by  inat- 
tention on  their  part,  or  by  injudicious  attempts  to  remove  or  lessen 
the  disease.  Wlien  neglected,  the  tumour  is  apt  to  increase  in  size 
till  it  projects  from  between  the  eyelids,  so  that  it  is  constantly  irri- 
tated, and  soon  becomes  inflamed,  from  contact  with  their  edges, 
the  eyelashes,  and  foreign  bodies.     In  such  circumstances,  the  pa- 


425 

tient  ought  to  submit  to  such  a  treatment  as,  if  carefully  conducted, 
shall  not  only  improve  very  materially  the  form  of  the  eye  by  les- 
sening the  staphyloma,  but  save  the  remaining  sight.  The  pa- 
tient, however,  must  be  informed  that  notwithstanding  the  removal 
of  the  partial  staphyloma,  it  will  be  impossible  for  him  to  recover 
I  the  transparency  of  the  cornea  in  the  part  affected.  There,  after 
I  the  most  successful  treatment,  a  very  visible,  white,  but  flat  cica- 
trice, will  remain. 

If,  either  from  closure  of  the  pupil,  or  from  the  partial  staphyloma 
being  situated  over  it,  and  consequently  involving  it,  no  vision  ex- 
i  ists,  we  must,  first  of  all,  direct  our  attention  to  the  diminution  of 
the  staphyloma,  and  removal  of  the  pain  and  irritation  by  which 
i  its  increase  in  size  is  attended;  and  then  determine  whether,  by 
!  an  operation  for  artificial  pupil,  we  are  likely  to  gain  for  tiie  pa- 
;  tient  some  restoration  of  sight. 

It  is  only  by  means  of  a  gradual,  moderate,  and  repeated  inflam- 
[  matory  process,  that  a  partial  staphyloma  can  be  removed,  without 
i  endangering  the  general  form  of  the  eye  and  the  remaining  degree 
1  of  vision.     The  inflammation  is  to  be  excited  by  the  cautious  use 
I  of  escharotics,   continued  till  such  a  firm  cohesion  is  produced  in 
I  that  part  of  the  cornea  which  is  adherent  to  the  iris,  that  it  shall 
be  able  to  resist  the  pressure  of  the  aqueous  humour.     The  eschar- 
otic  most  frequently  employed  for  this  purpose  is  that  preparation 
of  the  muriate  of  antimony  called  butter  of  antimony.     The  point 
.  of  a  camel-hair  pencil  being  dipt  in  this  pieparation,  and  the  eye- 
lids held  widely  separated,   the  apex  of  the  staphyloma  is  to  be 
touched  with  the  pencil  till  a  small  white  eschar  forms.     Before 
allowing  the  lids  to  close,  the  surface  of  the  staphyloma  is  to  be 
washed  with  a  large  camel-hair  pencil  dipped  in  milk.     The  re- 
petition of  the  caustic  is  not  to  take  place  till  the  eschar  shall  have 
separated,  and  the  inflammation  caused  by  the  former  application 
subsided. 

2.  Total  staphyloma  appears  under  two  different  forms,  the 
discrimination  of  which  is  necessary  both  for  the  prognosis  and  the 
technicism  of  the  operation  which  total  staphyloma  so  frequently 
requires.  In  the  one,  the  tumour  is  spherical ;  in  the  other,  it  has 
the  form  of  a  blunt  cone. 

There  is  this  remarkable  difference  in  the  structure  of  these  two 
varieties  of  total  staphyloma,  that  in  the  spherical^  there  exists  an 
adhesion  between  the  cornea  and  the  iris,  but  none  between  the  iris 
and  the  capsule  of  the  lens  ;  whereas  in  the  conical,  not  only  are 
the  cornea  and  iris  united,  but  also  the  iris  and  the  capsule  of  the 
lens.  In  the  spherical  staphyloma,  the  anterior  chamber  is  abol- 
ished ;  the  posterior  continues  to  exist.  In  the  conical,  both  cham- 
bers are  obliterated. 

As  by  the  abolition  of  both  chambers,  the  secretion  of  the  aque- 
ous humour  must  be  entirely  prevented,  we  can  easily  explain,  in 
the  first  place,  why  the  conical  staphyloma  never  reaches  that  great 
54 


426 

size  which  is  frequently  attained  b)""  the  spherical.  In  the  latter, 
the  posterior  chamber  remaining  entire,  that  portion  of  the  secreting 
organ  of  aqueous  humour  which  is  lodged  in  that  cavity,  and 
which,  if  the  conjectures  already  stated  are  correct,  is  the  chief  por- 
tion of  that  organ,  continues  its  functions,  and  by  its  overbalancing 
supply  of  aqueous  humour  forces  the  united  iris  and  cornea  to  ex- 
pand into  a  spherical  and  constantly  more  and  more  extenuated 
tumour ;  whereas  when  the  cornea,  iris,  and  capsule  of  the  lens 
are  all  glued  together  by  adhesive  inflammation,  as  they  are  in  con- 
ical staphyloma,  there  can  be  little,  if  any,  secretion  of  aqueous  hu- 
mour, so  that  when  once  a  staphyloma  of  this  kind  has  formed,  it 
will  ever  afterwards  'iiaintain  nearly  the  same  size. 

Another  circumstance  explained  by  this  morbid  anatomy  of 
staphyloma,  is  the  rarity  of  the  conical  variety,  in  comparison  of  the 
spherical.  The  cases  in  which  inflammation  extends  its  influence 
so  deeply  as  to  unite  the  cornea,  iris,  and  capsule  of  the  lens,  must 
evidently  occur  less  frequently  than  those  in  which  merely  the  cor- 
nea and  iris  are  affected. 

This  morbid  anatomy  of  staphyloma  serves  to  explain  a  third 
fact,  namely,  the  frequency,  or  rather  constancy  with  which  conical 
staphyloma  is  accompanied  by  varicose  dilatation  of  the  blood-ves- 
sels of  the  eye,  which  is  a  rare  attendant  on  spherical  staphyloma. 
The  inflammation  which  produces  the  former,  attacks  the  eye  much 
more  deeply  and  generally,  and  arises  more  frequently  from  syphi- 
lis, scrofula,  or  some  other  dyscrasia,  than  the  inflammation  which 
terminates  in  the  latter.  Hence  it  is,  that  along  with  the  conical 
variety  of  staphyloma,  the  whole  vascular  systems  of  the  eye  are 
left  in  a  state  inclining  to  varicose  degeneration.  The  actual  exist- 
ence of  this  state  manifests  itself,  not  merely  by  enlarged  vessels 
scattered  over  the  surface  of  the  eyeball,  but  by  a  dirty  blue  colour 
of  the  sclerotica,  and  after  a  time,  by  a  circle  of  dark  blue  varices 
of  the  choroidal  vessels,  shining  through  that  tunic,  which  has  be- 
come extenuated  from  their  pressure. 

As  to  the  size  which  is  attained  by  spherical  staphyloma,  that 
depends  very  much  on  the  degree  of  activity  possessed  by  the  source 
of  the  aqueous  humour,  which  resides  in  the  posterior  chamber. 
We  conclude  that  the  less  that  this  source  has  suffered  from  the 
preceding  inflammation,  the  greater  will  be  the  quantity  of  aqueous 
humour  secreted,  and  the  greater  consequently  the  expansion  of 
the  united  iris  and  cornea.  We  not  unfrequently  see  spherical 
staphyloma  become  so  thin  and  transparent,  from  distention  and 
interstitial  absorption,  that  the  patient  is  able  to  distinguish  a  num- 
ber of  objects  around  him,  and  is  sometimes  led  to  entertain  hopes 
of  a  conaplete  recovery  of  his  sight  from  the  operator.  This  ap- 
pearance is  always  the  forerunner  of  the  bursting  of  the  staphylo- 
ma, which  is  followed  by  a  sinking  awa}^  of  the  tumour  for  a  day 
or  two,  but  is  soon  succeeded  by  its  re-appearance  in  its  former 
shape,  and  with  its  former  dimensions. 


427 

There  is  another  circumstance  regarding  spherical  staphyloma 
which  merits  attention,  namely,  that  when  it  attains  a  large  size, 
the  iris,  (unable  to  expand  to  the  same  degree  as  the  cornea,  and 
its  texture  much  more  frail,)  becomes  torn  into  threads,  so  that 
when  we  examine  the  internal  surface  of  such  a  staphyloma,  after 
death,  or  after  it  has  been  removed  by  an  operation,  we  find  the 
iris  which  adheres  to  the  cornea,  broken  and  reticulated ;  whereas 
the  internal  surface  of  a  staphyloma  which  has  not  reached  a  great 
size  exhibits  the  iris  still  entire.* 

Prognosis.  There  is  no  possibility  of  restoring  sight  to  the 
patient  affected  with  total  staphyloma,  even  in  cases  where  there 
can  be  no  doubt  that  the  lens,  vitreous  humour,  and  retina,  are 
perfectly  sound.  All  that  we  can  do  in  the  way  of  relief  is  to  re- 
move a  tumour  which  is  extremely  unsightly,  frequently  very  pain- 
ful, and  even  dangerous  if  left  to  itself.  If  a  total  staphyloma  be 
combined  with  an  advanced  varicose  state  of  the  eye,  if  the  tu- 
mour be  of  such  size  that  it  can  no  longer  be  covered  with  the 
eyelids,  but  is  in  continual  contact  with  the  eyelashes,  and  con- 
stantly exposed  to  the  air  and  substances  floating  through  it,  if  in 
consequence  of  these  causes  the  cornea  becomes  inflamed,  and  the 
integuments  of  the  lower  lid  excoriated,  then,  the  most  trifling 
bruise  or  other  injury  may  bring  on  inflammatory  disorganization 
and  protrusion  of  the  whole  eye,  especially  if  the  staphyloma  is  of 
syphilitic,  scrofulous,  or  arthritic  origin.  It  is  proper,  therefore,  to 
remove  as  soon  as  possible  every  considerable  total  staphyloma. 

Treatment.  Many  proposals  have  been  made  for  removing 
total  staphyloma  without  operation.  The  application  of  the  mu- 
riate of  antimony  has  been  particularly  tried,  in  consequence  of  the 
recommendation  of  Richter.  It  was  also  supposed  that  by  mere 
incision  of  the  staphyloma,  passing  a  thread  through  it,  or  excision 
of  a  small  part  of  it,  so  that  the  eye  v:as  kept  for  a  certain  time 
in  a  state  of  evacuation,  the  cure  of  this  disease  could  be  accom- 
plished.! All  these  means  have  been  found  to  fail ;  and  in  many 
cases,  especially  when  escharotics  w^ere  tried,  they  were  found  to 
excite  the  eye  into  a  state  terminating  in  exophthalmia.  Beer,  on 
the  other  hand,  mentions  that  he  had  removed  216  staphylomata 
by  operation,  and  that  in  not  a  single  instance  had  any  dangerous 
accident  followed. J 

Operation.  The  operation  for  total  staphyloma  consists,  first, 
in  the  formation  of  a  flap  with  the  knife,  and  secondly,  in  the  re- 
moval of  that  flap  with  the  scissors. 

While  the  assistant  keeps  the  upper  eyelid  raised  by  means  of 
Pellier's  speculum,  a  pretty  large  hook  is  to  be  passed  through  the 
centre  of  the  staphyloma.     In  the  hand  which  does  not  hold  the 

*  Beer's  Ansicht  des  staphylematosen  Metamorphosen  des  Auges.     Plate  1.  fig. 
1  &  2.     Wien,  1805. 
t  Celsus  de  Re  Medica,  Lib.  vii.  Pars  ii.  Cap.  i.  Sect.  2. 
t  Lehre  von  den  Augenkrankheiten.    Vol.  ii.  p.  216.    Wien,  1817. 


428 

hook,  the  surgeon  takes  the  staphyloma-knife,  which  is  nothing; 
more  than  the  cataract-knife  somewhat  enlarged.  With  the  cut- 
ting edge  directed  upwards,  the  staphyloma  is  to  be  penetrated  at 
its  temporal  edge,  close  to  its  basis,  and  at  such  a  distance  below 
its  transverse  diameter  that  two-thirds  of  the  tumour  shall  be  in- 
cluded in  the  incision  to  be  made  with  the  knife.  The  point  of  the 
knife  ought  to  be  passed  perpendicularly  into  the  staphyloma. 
Having  penetrated  through  the  cornea  and  iris,  the  handle  is  to 
be  carried  backwards  till  the  instrument  is  brought  into  a  position  par- 
allel to  the  basis  of  the  staphyloma.  The  knife  is  now  to  be  carried 
onwards  till  it  reaches  the  point  of  exit,  which  ought  to  be  in  a 
horizontal  line  with  the  point  of  entrance.  The  flap  is  completed 
by  the  progressive  motion  of  the  knife,  till  it  fairly  cuts  itself  out. 
The  operation  is  instantly  to  be  completed,  by  dividing  with  the 
curved  scissors  that  part  of  the  circumference  of  the  staphyloma 
which  remains  in  connexion  with  the  sclerotica.  At  the  same  mo- 
ment, the  assistant  lets  fall  the  upper  eyelid,  which  must  not  again 
be  raised  for  eight  days. 

During  the  whole  of  the  operation,  and  especially  towards  the 
end  of  it,  care  must  be  taken  that  the  eyeball  is  not  iiregularly  and 
forcibly  pressed,  as  this  might  readily  give  rise  to  the  loss  of  the 
lens  and  vitreous  humour,  which,  in  oil  cases,  at  least  of  spherical 
staphyloma,  may  and  ought  to  be  preserved.  In  cases  of  conical 
staphyloma,  it  is  scarcely  possible  to  avoid  the  loss  of  the  lens,  and 
part  of  the  vitreous  humour  ;  and  not  unfrequently  the  whole  con- 
tents of  the  eye  are  evacuated.  This  is  owing  to  the  adhesion 
which  subsists  in  this  kind  of  staphyloma  between  the  capsule  of 
the  lens  and  the  iris,  so  that  the  knife  actually  passes  behind  the 
lens  and  tLrciigh  the  vitreous  humor. 

If  the  sclerotica  has  taken  a  considerable  share  in  the  disease, 
anct  ihere  are  a  number  of  dark-blue  varicose  protuberances  round 
the  Gtaphylomatous  cornea,  rather  than  confine  the  operation  to 
the  removal  of  the  cornea  and  iris  merely,  it  is  better  to  take  away 
the  anterior  third  of  the  eyeball ;  an  operation  which  though  oc- 
casionally followed  by  shrinking  of  the  remains  of  the  eye  to  a 
very  small  size,  in  general  leaves  it  sufficiently  large  to  support  an 
artificial  eye. 

After  the  operation  for  staphyloma,  strips  of  court-plaster  are  to 
be  applied  so  as  to  keep  the  lids  of  both  eyes  from  moving. 

If  the  vitreous  humour,  and  more  especially  if  the  lens,  has  been 
preserved,  we  generally  find  on  examining  the  eye  eight  days  after 
the  operation,  that  a  greyish,  semi-transparent,  and  flat  pseudo- 
cornea  is  already  produced,  through  which  the  patient,  were  we 
to  allow  him,  might  be  able  to  distinguish  a  number  of  objects. 
Gradually  this  membrane  becomes  opaque,  till  at  last  the  place  of 
the  staphylomatous  cornea  presents  a  firm  cicatrice,  with  bluish  or 
brownish  streaks.  The  eyeball  has,  as  to  its  form,  lost  only  the 
projection  of  the  cornea,  having  there  become  flat.     When  it  has 


429 

completely  recovered  from  the  operation,  an  artificial  eye  may  be 
applied,  by  which  a  high  degree  of  illusion  may  be  produced. 

It  occasionally  happens,  especially  in  cases  of  staphyloma  attend- 
ed with  varicosity  of  the  internal  vessels  of  the  eye,  that  either  im- 
mediately, or  some  hours  after  the  operation,  haemorrhage  takes 
place  both  from  the  eye  and  into  the  vitreous  cells.  Injected  with 
blood,  the  vitreous  humour  protrudes  to  such  an  extent  from  the 
wound,  that  it  is  impossible  to  keep  the  eyelids  shut.  The  eyeball 
is  painfully  distended,  while  the  conjunctiva  and  lids  become  greatly 
ecchymosed.  The  haemorrhage  into  the  eye  gives  rise  in  some 
cases  to  agonizing  pain,  and  may  even  bring  on  convulsions. 
Under  such  circumstances,  it  may  not  be  improper  to  cut  away 
with  the  scissors,  the  protruding  hyaloid  membrane,  which  presents 
a  solid  and  dark-purple  mass,  hanging  from  the  front  of  the  eye. 
After  this  is  done,  the  bleeding  ceases,  and  the  pain  abates.  Left 
to  itself,  the  protrusion  dies  away  in  the  course  of  a  few  days. 
The  eye  is  apt  in  either  case  to  shrink  below  the  usual  size  of  a 
staphylomatous  eye  after  operation. 

Violent  inflammation  sometimes  supervenes  to  the  operation  for 
staphyloma,  ending  in  suppuration,  both  within  the  eyeball  and  in 
the  surrounding  cellular  membrane.  This  must  be  combated  by 
a  strict  antiphlogistic  plan  of  treatment,  opiates  will  be  required  to 
abate  the  severity  of  the  pain,  a  poultice  is  to  be  laid  over  the  eye, 
and  any  abscess  which  may  form  is  to  be  immediately  opened  with 
the  lancet. 

It  occasionally  happens  that  the  opening  into  the  eye,  formed 
by  the  removal  of  the  staphylomatous  cornea  and  iris,  is  long  of 
closing,  no  pseudo-cornea  being  present  when  we  open  the  lids  on 
the  eighth  or  tenth  day,  and  even  for  weeks  the  clear  humours 
lying  uncovered  behind  the  gap  in  the  front  of  the  eye,  till  at  length 
the  aperture  contracts  and  cicatrizes. 

3.  Staphyloma  of  the  Choroid  and  Sclerotica. 

I  have  nothing  to  add  to  what  has  been  said  on  this  head,  in 
the  twenty-second  section  of  last  chapter,*  except  that  when  a 
staphyloma  of  this  sort  on  the  front  of  the  eye  is  very  prominent 
and  insulated,  I  see  no  reason  why  it  should  not  be  removed  like 
a  staphyloma  of  the  cornea  and  iris. 


SECTION     XIII.— -VARICOSITY     OF     THE     EXTERNAL     AND     IN- 
TERNAL   VESSELS    OF    THE    EYE. 

Two  sets  of  blood-vessels  belonging  to  the  eye  are  apt  to  be  left 
in  a  state  of  varicose  distension,  after  certain  of  the  ophthalmiae ; 
namely,  the  visible  arteries  of  the  sclerotica,  after  arthritic  iritis, 
and  the  vasa  vorticosa  of  the  choroid,  after  choroiditis. 

♦  See  p.  381. 


430 

Little  can  be  done,  and  nothing  directly,  to  remove  this  state  of 
the  vessels,  which  is  not  only  in  general  beyond  cure,  but  affords 
a  very  unfavourable  index  of  the  condition  of  the  humours  and 
retina.  Glaucoma  and  amaurosis,  in  almost  every  case,  are  sooner 
or  later  added  to  varicose  distension  of  the  blood-vessels  of  the  eye. 


SECTION  XIV. AMAUROSIS. 


Complete  or  incomplete  insensibility  of  the  retina  to  light  is  a 
frequent  consequence  of  inflammation,  especially  when  it  has  af- 
fected the  internal  textures  of  the  eye ;  as,  the  retina,  the  choroid, 
or  the  iris.  When  the  inflammation  has  been  completely  subdued, 
but  the  amaurosis  continues,  recovery  of  sight  may  be  regarded  as 
hopeless. 


SECTION  SV. OSSIFICATION  IN  DIFFERENT  PARTS  OF  THE  EYE. 

Ossification,  or  calculous  deposite,  certainly  occurs  as  an  occa- 
sional sequela  of  long-continued  ophthalmia ;  and,  indeed,  it  may 
be  suspected  that  in  all  instances,  and  in  w^hatever  texture  of  the 
body  an  unnatural  formation  of  osseous  substance  takes  place,  it  is 
preceded  by  a  certain  kind  or  degree  of  inflammatory  action. 

1.  Ossification  of  the  cornea. 

Yoigtel  mentions,  that  in  the  Walterian  Museum  at  Berhn,  there 
was  a  piece  of  cornea  preserved,  which  had  been  converted  into 
bone.     It  was  three  hues  long,  two  broad,  and  weighed  two  grains.* 

Mr.  Wardrop  relates,  that  in  dissecting  an  eye  of  which  no  his- 
tory could  be  obtained,  he  found  several  gritty  particles  and  inequal- 
ities on  the  internal  surface  of  the  cornea. 

He  also  states  that  on  maceration  of  an  eye  which  was  changed 
in  form,  and  the  cornea  opaque,  a  piece  of  bone,  weighing  two  grains, 
oval  shaped,  hard,  and  smooth,  was  found  between  the  laminae. 
A  piece  of  bone  was  present  between  the  choroid  coat  and  retina  of 
the  same  eye.t 

2.   Osseous  DejJosite  in  the  Anterior  Chamber. 

Mr.  Anderson,  surgeon  at  Inverary,  communicated  to  Mr.  Ward- 
rop, that  on  examining  the  right  eye  of  a  woman  of  31  years  of  age, 
he  observed  a  substance  of  a  whitish  appearance,  arising  from  the 
inside  of  the  sclerotic  coat,  and  extending  upwards  behind  the  cor- 
nea, over  a  great  part  of  the  iris,  to  very  near  the  pupil.  It  had 
produced  much  irritation  in  the  eye,  with  inflammation,  severe  pain, 
an  almost  constant  flow  of  tears,  inability  to  bear  the  light,  and  a 
considerable  diminution  of  vision.     The  eye  was  less  in  size  than 

*  Handbuch  der  Patholorischen  Anatomic.     Vol.  ii.  p.  92.  Halle,  1804. 
t  Morbid  Anatomy  of  the  Human  Eye.  Vol.i.  p.  74.     London,  1819. 


431 

the  other.  The  complaint  was  the  consequence  of  a  fall,  fifteen 
years  before,  at  the  root  of  a  tree,  by  which  the  patient  struck  the 
eye,  but  did  not  cut  any  part  of  it.  From  this  period,  the  substance 
seen  through  the  cornea  had  begun  to  grow,  and  had  gradually  in- 
creased in  size.  The  pain  and  other  symptoms  had  been  suffera- 
ble  until  about  nine  months  before  Mr.  Anderson  saw  her,  when 
the  complaint  became  more  violent.  He  made  an  incision  into  the 
cornea,  in  the  manner  recommended  for  the  extraction  of  the  catar- 
act, raised  the  flap  of  the  cornea  with  a  flat  crooked  probe,  and  with 
the  same  instrument  turned  out  a  small  piece  of  bone.  The  upper 
part  of  it  was  as  thin  as  a  piece  of  paper  ;  at  the  under  part,  it  was 
thicker,  porous,  and  brittle,  and  of  an  irregular  semilunar  form. 
The  upper  part  was  quite  detached,  the  under  part  shghtly  adhered 
to  some  part  of  the  globe  out  of  sight ;  but  it  was  easily  extracted, 
without  requiring  the  knife  to  separate  its  adhesions.  From  the  un- 
steadiness of  the  patient,  it  was  impossible  to  discover  from  what 
part  the  ossification  originated.* 

Mr.  Wardrop,  in  his  second  volume,  mentions  that  a  case  similar 
to  Mr.  Anderson's  had  come  within  his  own  observation,  thin  lam- 
inae of  bone  having  been  discharged  at  several  times  from  the  an- 
terior chamber,  through  ulcers  formed  in  the  cornea;  and  that  he 
also  had  had  an  opportunity  of  examining  a  case  under  Mr.  Wis- 
hart's  care,  where  that  portion  of  the  capsule  of  the  aqueous  humour 
which  is  reflected  over  the  iris,  was  almost  entirely  converted  into  a 
bony  shell.! 

3.   Ossification  of  the  Choroid  Coat. 

Voigtel  has  described  various  preparations  belonging  to  the  Wal- 
terian  Museum,  in  which  the  choroid  coat  was  more  or  less  com- 
pletely ossified.  In  one,  the  posterior  half  was  so  affected  ;  in  oth- 
ers, the  anterior  part ;  in  some,  the  whole  choroid.  He  also  quotes 
from  Giinz,  an  instance  of  ossification  between  the  lamellae  of  the 
choroid  coat.+ 

Mr.  Wardrop,  under  the  head  of  ossification  of  the  choroid,  men- 
tions that  he  had  met  with  a  few  instances  of  a  thin  cup  of  bone 
between  the  sclerotic  coat  and  the  retina  ;  that  the  retina  was  in 
immediate  contact  with  the  interior  surface  of  the  bone,  but  that  be- 
tween the  sclerotic  coat  and  the  ossification  there  was  a  very  thin, 
tender,  and  pale-coloured  membraneous  expansion,  the  only  vestige 
of  the  choroid  ;  and  that  at  the  bottom  of  the  cup,  there  was  a  small 
round  perforation,  through  which  the  retina  passed  to  expand  on 
the  interior  surface  of  the  osseous  shell.§  It  may  be  doubted  whe- 
ther such  cases  were  not  rather  ossifications  of  the  membrana  Jaco- 
biana,  than  of  the  choroid. 

*  Ibidem,  p.  75. 

t  Ibidem.  Vol.  ii.  p.  18.     London,  1818. 

t  Handbuch  der  Pathologischen  Anatomic.     Vol.  ii.  p.  97.     Halle,  1804. 

§  Morbid  Anatomy  of  the  Human  Eye.  Vol.  ii.  pp.  &i  and  272.  Lond.  1818. 


432 

4.   Ossification  of  the  Retina. 

Morgagni,  Morand,  and  others,  have  recorded  instances  of  cup- 
like ossifications  within  the  choroid,  and  whicii  have  generally  been 
accounted  as  situated  in  the  retina. 

Morgagni  says,  that  in  the  case  which  fell  under  his  observation, 
instead  of  the  retina,  there  was  a  thin  bony  lamella  under  the  cho- 
roid universally.* 

In  Morand's  case,  the  proper  retina,  by  which  I  understand  the 
medullary  and  vasculo-cellular  layers  of  that  membrane,  appears  to 
have  been  enveloped  by  the  osseous  substance,  so  that  we  may  con- 
clude that  it  was,  partly  at  least,  the  membrana  Jacobiana,  or  ex- 
ternal layer,  which  was  ossified,  along  with  the  hyaloid  membrane. 
The  patient  had  been  blind  of  the  eye  thus  affected  for  twenty 
years  ;  when  about  fifteen,  he  had  had  a  violent  inflammation  of 
that  eye,  followed  by  the  formation  of  a  yellow  cataract,  which  seve- 
ral oculists  had  offered  to  remove  by  operation,  but  the  patient 
would  never  consent.t 

5.   Ossification  of  the  Hyaloid  Membrane,   Crystalline  Cap- 
sule, and  Crystalline  Lens. 

Many  examples  have  been  recorded  of  ossification  of  the  crys- 
talUne  lens  and  capsule ;  and  in  some  of  these,  the  hyaloid  mem- 
brane has  been  more  or  less  affected  in  the  same  manner. 

"  In  one  case,"  says  Mr.  Wardrop,  "  besides  the  capsule  of  the 
lens  being  ossified,  I  found  several  large,  but  thin  scales  of  bony 
matter,  dispersed  in  an  irregular  manner  throughout  the  vitreous 
humour,  which,  in  all  probability,  were  ossifications  of  the  hyaloid 
membrane."  + 

Ossification  of  the  capsule  appears  to  be  much  more  frequent 
than  of  the  substance  of  the  lens.  In  one  case  of  capsular  cataract, 
I  found  the  anterior  hemisphere  of  the  capsule  hard  and  gritty  un- 
der the  needle.  The  disease  had  originated  in  iritis,  followed  by 
contracted  pupil  and  lymphatic  exudation.  The  cataract  was  de- 
pressed, and  a  tolerable  share  of  vision  was  restored. 

In  some  cases,  the  whole  capsule  is  converted  into  a  thin  shell  of 
bone,  containing  the  lens  in  an  opaque  state.  In  other  cases,  the 
lens  had  been  previously  absorbed  in  part  or  completely,  so  that  the 
ossified  capsule  has  a  less  regular  form,  having  become  shrivelled 
previous  to  being  converted  into  bone. 

In  an  eye  sent  to  Mr.  Wardrop  by  Mr.  Allan  Burns,  the  central 
portion  of  the  lens  was  found  converted  into  a  hard  bone.  This  is 
the  only  instance  which  Mr.  W.  had  met  with,  in  which  ossifica- 
tion of  the  lens  was  unattended  by  ossification  of  the  capsule.  The 
ossified  centre  of  the  lens  was  of  a  deep  brown  colour,  and  exhibited 
a  laminated  structure.§ 

*  De  Sedibus  et  Causis  Morborum.     Epist.  li.  Art.  30. 

t  Memoires de  1' Academie  Royale  des  Sciences,  pour  1730,  p.  467.  Amsterdam,  1733. 
X  Morbid  Anatomy  of  the  Human  Eye.  Vol.  ii.  pp.  128  and  271.  London,  1818. 
§  Ibidem,  pp.  96  and  261. 


433 

Pellier  relates  an  interesting  case,  in  which  the  cornea  of  an  eye, 
which,  for  twenty  years,  had  suffeted  more  or  less  from  inflamma- 
tion, at  length  gave  way,  and  allowed  an  ossified  lens  to  be  seen 
and  felt.  A  crucial  incision  was  made  through  the  cornea,  and  a 
portion  of  calculous  substance  of  the  size  of  a  kidney-bean  was  ex- 
tracted. Part  of  the  ossification  was  still  left  in  the  eye,  the  pa- 
tient having  become  so  restless  that  it  could  not  be  removed.  Pel- 
lier seems  to  think  that  the  whole  contents  of  the  eye  were  in  an 
ossified  state.     The  piece  extracted  was  rough  and  irregular.* 

A  careful  perusal  of  the  cases  recorded  of  ossification  in  different 
parts  of  the  eye,  will  confirm,  in  a  very  striking  manner,  the  re- 
mark with  which  I  commenced  this  section,  namely,  that  this 
morbid  change  has  generally  been  the  consequence  of  long-contin- 
ued inflammation. 

As  for  the  diagnostic  signs  of  this  state  of  the  eye,  they  must  be 
obscure,  for  the  pupil  is  generally  contracted  in  such  cases,  and  the 
eye  atrophic. 


CHAPTER  XII. 

ADAPTATION  OF  AN  ARTIFICIAL  EYE. 

When  the  eye  and  eyelids  have  been  destroyed,  or  removed  in 
consequence  of  disease,  a  painted  imitation  of  these  parts  has  some- 
times been  applied  over  the  front  of  the  orbit,  and  kept  in  its  place 
by  means  of  a  steel-spring  going  round  the  temple  to  the  opposite 
side  of  the  head ;  t  but  by  an  artificial  eye  is  generally  meant  a 
hollow  plate  of  enamel,  made  to  resemble  the  front  of  the  natural 
eye,  and  introduced  behind  the  eyehds.  Enamelled  plates  of  gold 
were  formerly  used  for  this  purpose,  but  at  the  present  day  artificial 
eyes  are  generally  made  altogether  of  enamel. 

An  artificial  eye  ought  to  be  perfectly  smooth,  and  of  such  a  form 
and  size  as  to  cover  the  remainder  of  the  natural  eye  without  pres- 
sing much  on  it,  or  irritating  it  in  any  way.  Its  edge  ought  not 
to  be  sharp,  but  rather  thick  and  round.  The  internal  surface  of 
the  middle  portion,  which  represents  the  cornea,  ought  to  be  con- 
cave, and  neither  flat,  nor,  as  we  even  sometimes  find  it,  convex, 
which  forms  must  necessarily  give  rise  to  pressure  on  the  eye,  un- 
less it  be  much  shrunk.  Want  of  attention  to  these  particulars  is 
often  the  cause  of  the  pain  which  patients  feel  from  the  introduc- 
tion of  an  artificial  eye,  and  which  often  leads  them  to  resign  all 
thoughts  of  continuing  its  use. 

*  Recueil  de  Memoires  et  d' Observations.     Obs.  139.     Montpellier,  1783> 
t  CEuvres  d' Ambrose  Pare )  Liv.  xxiii.  Chap.  i. 

55 


434 

Thinness  and  lightness  are  indispensable  requisites  of  an  artifi- 
cial eye.  When  the  remains  of  the  natural  e5"e  are  large,  unless 
the  artificial  eye  is  thin,  the  lids  are  too  much  pressed  out,  and  are 
prevented  from  executing  their  usual  movements. 

If  the  remains  of  the  eye  are  irregular  in  form,  the  artificial  eye 
must  be  made  so  too,  lest  it  press  unequally  and  injuriously  against 
any  part.  When  the  upper  eyelid,  for  example,  is  partially  adher- 
ent to  the  remains  of  the  eyeball,  the  diameter  of  the  artificial  eye 
from  above  downwards  must  be  shorter  than  common,  or  it  must 
have  a  notch  in  its  edge  opposite  to  the  point  of  adhesion. 

The  particular  hue  of  the  white  of  the  eye,  the  appearance  of 
the  vessels  strewed  over  it,  and  the  size  and  colour  of  the  iris,  ought 
to  be  exactly  imitated  from  the  sound  eye.  The  pupil  ought  to  be 
represented  at  its  medium  degree  of  expansion,  and  the  appearance 
of  an  anterior  chamber  ought  to  be  given.  I  have  observed,  how- 
ever, that  the  iris  looks  darker,  when  the  eye  is  introduced  behind 
the  eyehds,  than  it  does  when  examined  in  the  hand. 

If  the  defective  eye,  which  the  patient  is  desirous  of  covering 
from  view,  is  not  larger  than  the  natural  size,  an  artificial  eye  may 
be  worn  without  an)'  previous  surgical  operation.  If.  on  the  other 
hand,  there  is  staphyloma  present,  this  must  first  be  removed. 
The  injur}'  which  has  rendered  the  application  of  an  artificial  eye 
desirable,  or  any  operation  which  has  been  performed  on  the  eye, 
must  first  be  completely  cured,  and  an  additional  space  of  some 
months  must  have  elapsed  before  the  artificial  eye  can  with  pro- 
priety be  tried.  In  some  cases,  indeed,  from  the  great  irritability 
of  the  patient,  causing  a  tenderness  and  epiphora  which  cannot  be 
subdued,  or  from  the  nature  of  the  disease  in  which  the  loss  of 
the  eye  took  place,  giving  ground  to  dread  that  irritation  might 
bring  on  perhaps  some  malignant  disease  within  the  orbit,  we  are 
obliged  to  resign  all  thoughts  of  applying  an  artificial  e3^e. 

If  there  is  no  inflammation,  no  fungous  excrescence  from  the 
eyeball  or  eyelids,  no  pain  or  irritation  present,  we  may  begin  with 
a  small  pldin  enamel  eye,  about  three  quarters  of  an  inch  long  and 
half  an  inch  broad. 

The  mode  of  introducing  an  artificial  eye,  is  to  lay  hold  of  it  by 
its  lower  edge  with  the  thumb  and  forefinger  of  the  right  hand, 
dip  it  in  water,  with  the  left  thumb  raise  the  upper  e3'elid,  intro- 
duce the  upper  edge  of  the  aitificial  eye  under  this  lid,  and  press  it 
up  into  the  upper  fold  of  the  conjunctiva,  till  its  most  prominent 
partis  hid  behind  the  hd,  turn  this  part  of  the  artificial  eye  towards 
the  outer  canthus,  allow  the  upper  lid  to  descend  over  the  artificial 
eye,  w^hich  is  now  to  be  supported  with  the  right  thumb,  while 
with  the  left  fore-finger,  the  lower  eyehd  is  to  be  forcibly  drawn 
downwards,  which  allows  the  artificial  eye  to  slide  behind  it  into 
the  lower  fold  of  the  conjunctiva. 

For  some  days,  the  artificial  eye  is  to  be  worn  only  during  a 
few  hours.     It  is  withdrawn  with  the  aid  of  a  gold  or  silver  probe,  of 


435 

the  thickness  of  a  knitting  needle,  the  end  of  which  is  rounded  off 
and  bent  into  the  form  of  a  hook.  With  the  fore-finger  of  the  left 
hand,  the  lower  hd  is  to  be  depressed,  so  as  to  allow  the  hook  to  be 
introduced  behind  the  edge  of  the  artificial  eye,  which  by  its  means 
is  to  be  raised  till  it  is  no  longer  grasped  by  the  lower  lid  ;  the  ar- 
tificial eye  immediately  glides  from  the  upper  fold  of  the  conjuncti- 
va, and  is  to  be  laid  hold  of  by  the  left  hand.  The  eye  is  to  be  im- 
mediately washed  in  clean  cold  water  to  free  it  from  the  mucus 
which  adheres  to  it,  and  laid  aside  till  next  day. 

The  patient  is  soon  able  to  introduce  and  withdraw  the  artifi- 
cial eye  without  assistance.  While  withdrawing  it,  he  leans  over 
a  bed,  in  order  that  if  it  should  fall  it  may  not  be  broken. 

If  the  eyeball  shrinks  to  a  very  small  size,  or  if  it  be  removed, 
the  eyelids  lose  that  support  and  elasticity  necessary  for  the  per- 
formance of  their  motions  ;  the  consequence  is,  that  they  soon  be- 
come entirely  motionless,  and  sink  into  the  orbit,  while  the  folds 
of  the  conjunctiva,  which  in  the  natural  state  of  the  parts  extend 
over  the  anterior  third  of  the  eyeball,  gradually  become  contracted, 
and  at  last  almost  abolished.  The  superabundant  tears  and  mu- 
cus cannot  be  properly  excreted,  being  no  longer  pressed  forward 
by  the  convexity  of  the  eyeball,  but  gather  behind  the  hds  and 
adhere  to  their  edges  and  angles,  while  the  nostril  of  the  same 
side  feels  dry.  These  symptoms  are  in  general  greatly  lessened 
by  the  use  of  an  artificial  eye,  which  affords  to  the  lids  a  new  sup- 
port, restores  to  them  the  elasticity  necessary  for  their  motions, 
and  expands  again  the  folds  of  the  conjunctiva ;  while  the  renewed 
action  of  the  lids  serves  to  convey  the  tears  and  mucus  to  the 
puncta  lachrymalia,  as  in  the  state  of  health.  In  such  cases,  we 
must  commence  with  a  very  small  artificial  eye,  and  employ  larger 
ones,  proportionally  as  the  folds  of  the  conjunctiva  will  admit. 
We  need  not  be  afraid  thaL  a  very  small  eye  will  in  such  circum- 
stances fall  out  from  between  the  lids,  for  v/e  may  observe  that  the 
lids  are  enabled  to  open  only  in  proportion  to  the  size  of  the  eye 
which  is  placed  behind  them. 

I  have  said  that  we  may  begin  with  the  use  of  a  small  plain 
eye  ;  by  which  I  mean  one  without  any  representation  of  the  iris. 
A  series  of  such  eyes  ought  to  be  kept  by  the  oculist,  and  em- 
ployed till  the  patient  becomes  accustomed  to  their  use.  The  hds 
cannot  in  general  be  easily  moved  at  first  over  an  artificial  eye,  so 
that  it  remains  exposed  to  the  foreign  matters  driven  through  the 
air,  and  both  from  this  cause,  and  from  the  first  attempts  of  the 
patient  to  remove  and  replace  it,  is  apt  to  become  scratched,  which 
very  soon  destroys  its  appearance.  Every  two  or  three  days,  a 
larger  eye  ought  to  be  introduced,  till  at  length  the  lids  shell  ap- 
pear to  have  reached  nearly  their  natural  degree  of  expansion. 
The  artificial  eye  ought  always  to  be  somewhat  smaller  than  the 
natural  size.  The  iris  and  pupil  of  the  eye  which  is  to  be  used 
permanently  must  correspond  in  direction  with  those  of  the  sound 


436 

eye,  and  must  not  be  placed  nearer  to  either  canthus,  else  the  pa- 
tient will  appear  to  squint  with  the  artificial  eye.  Some  artificial 
eyes  are  made  for  the  right  or  left  side  only,  and  have  more  scle- 
rotica above  than  below  the  iris,  others  are  intended  to  be  used  on 
either  side,  and  have  the  iris  placed  midway  between  the  upper 
and  lower  edges  of  the  eye.  In  all  artificial  eyes,  there  is  more 
sclerotica  on  the  temporal  than  on  the  nasal  side  of  the  iris. 

A  properly  adapted  artificial  eye  performs  the  same  motions  as 
the  sound  eye,  especially  if  the  remains  of  the  eyeball  over  which 
it  is  placed  are  considerable,  and  are  moved  with  facility  by  the 
recti.  The  motion  of  the  artificial  eye,  however,  does  not  depend 
upon  this  alone,  but  also  on  the  motion  of  the  conjunctiva  and 
its  folds,  into  which  the  artificial  eye  is  received,  and  which  possess 
a  simultaneous  movement  w*ith  the  eyeball  and  eyelids.  Hence 
it  is  that  if  the  artificial  eye  is  of  a  proper  size,  neither  too  small 
so  as  to  escape  the  influence  of  the  conjunctiva,  nor  too  large  so 
as  to  prevent  that  influence,  we  find  that  it  performs  all  the  ordi- 
nary motions  of  the  eye,  even  when  the  stump  which  is  covered  is 
very  small. 

An  artificial  eye  soon  begins  to  suffer  from  the  influence  of  the 
tears  and  mucus,  so  that  the  cornea  becomes  dim  from  the  enamel 
losing  its  pohsh.  It  has  been  supposed  that  it  is  the  Meibomian 
secretion  which  is  chiefly  detrimental.  The  polish  is  never  com- 
pletely preserved  for  longer  than  three  or  four  months  ;  and  gen- 
erally in  six  months  the  whole  surface  of  the  enamel  is  rough  and 
hazy.  The  rapidity  with  which  this  process  goes  on,  varies  in 
different  individuals,  depending  on  the  peculiar  qualities  of  the  se- 
cretions. This  is  a  circumstance  which  puts  it  completely  out  of 
the  power  of  any  but  those  in  easy  circumstances  to  use  artificial 
eyes.  Others  must  submit  to  conceal  the  defective  eye  behind  a 
dark  coloured  glass,  or  if  its  appearance  is  very  unsightly,  to  hide 
it  wnth  a  shade.  They  ought  never  to  adopt  the  practice  of  cov- 
ering it  closely  up  with  a  piece  of  black  plaster,  which  heats  the 
eye  too  much,  and  renders  the  parts  inflamed  and  cedematous. 

Enamel  eyes  which  have  lost  their  polish,  prove  hurtful,  their 
roughness  exciting  the  conjunctiva  to  inflammation,  excoriation, 
and  the  growth  of  fungous  excrescences.  When  an  artificial  eye, 
therefore,  is  observed  to  have  become  dim,  and  to  be  producing  ir- 
ritation, it  must  no  longer  be  used,  any  irritation  already  present 
must  be  calmed,  and  when  the  parts  are  again  perfectly  free  from 
pain  or  inflammation,  a  new  artificial  eye  may  be  applied,  but  it 
will  generally  be  necessary  to  begin  with  a  small  one,  as  at  the 
first. 

When  we  wish  an  artificial  eye  made  expressly  for  any  particu- 
lar person,  it  is  necessary  to  send  to  the  enameller  a  front  view  of 
the  sound  eye,  representing  accurately  the  colour  and  other  appear- 
ances of  the  iris,  along  with  a  model  in  wood  or  lead  of  the  size 
and  form  of  the  artificial  eye  which  is  to  be  made,  taking  the  con« 


437 

vexity  of  this  model  from  the  sound  eye,  and  marking  on  it  the 
place  and  size  of  the  iris  and  pupil.  The  drawing  and  models 
ought  to  be  kept  by  the  enameller,  so  that  at  any  future  time  the 
patient  can  have  an  eye  made  after  them,  and  sent  to  him,  without 
further  trouble. 

In  the  use  of  an  artificial  eye,  the  strictest  regard  to  cleanliness 
must  be  observed.  Every  twelve  hours  the  eye  must  be  taken  out 
and  freed  from  the  mucus  which  adheres  to  it,  and  accumulates  in 
its  cavity.  The  eyelids  and  orbit  must  at  the  same  time  be  bathed 
with  tepid  milk  and  water,  and  should  there  be  any  considerable 
relaxation  of  parts,  with  a  tendency  to  puro-mucous  inflammation, 
a  slightly  astringent  collyrium  may  be  employed,  the  lunar  caustic 
solution  apphed  to  the  conjunctiva  at  bedtime,  and  the  edges  of  the 
lids  smeared  with  a  httle  red  precipitate  salve. 


CHAPTER  XIII. 


PARTIAL  AND  GENERAL  ENLARGEMENTS  OF  THE  EYEBALL ; 
EFFUSIONS  AND  TUMOURS  WITHIN  ITS  COATS. 

SECTION  1. CONICAL  CORNEA,* 

In  some  individuals,  the  cornea,  as  appears  to  have  been  first  ob- 
served by  Leveille,  the  French  translator  of  Scarpa  on  the  Diseases 
of  the  Eye,t  instead  of  its  natural  spherical  shape,  presents  the  form 
of  a  cone,  more  or  less  acute.  Viewed  from  one  side,  the  cornea 
in  this  state  looks  like  a  solid  piece  of  glass,  projecting  from  the 
front  of  the  eye.  The  cone  in  some  cases  is  pointed,  in  others,  al- 
though it  projects  more,  its  apex  is  rounded  off.  The  apex  of  the 
~cone  is  generally  in  the  centre  of  the  cornea,  but  sometimes  to  one 
side  of  it.  In  certain  positions  of  the  eye,  the  point  of  the  cone  ap- 
pears less  transparent  than  the  rest  of  the  cornea,  and  in  some  cases 
is  actually  nebulous  or  opaque.  On  placing  the  patient  directly 
opposite  to  a  window,  the  projecting  centre  of  the  cornea,  instead  of 
transmitting  the  light,  reflects  it  with  such  force  as  to  produce  a 
sparkling  effect.  As  this  takes  place  precisely  in  front  of  the  pupil, 
which  is  of  course  contracted  from  the  direct  exposure  to  the  light, 
it  necessarily  follows,  that  the  patient  can  distinguish  objects  only 
confusedly.  He  probably  sees  them  as  a  person  with  a  healthy 
eye  would  do,  when  looking  through  a  plano-convex  lens. 

In  the  early  periods  of  tliis  disease,  short-sightedness  is  the  prin- 
cipal effect  which  it  produces  on  the  vision  ;  when  more  advanced, 
nothing  is  seen  by  the  patient  through  the  centre  of  the  cornea  ;  all 
the  sight  which  he  enjoys  is  either  over  the  nose  or  towards  the 

*  Staphyloma  pellucidum. 

t  Traite  Pratique  des  Maladies  des  Yeux.  Tome  ii.  p.  179.     Paris,  1802. 


438 

temple,  and  ia  its  sphere  is  extremely  limited.  Still,  however,  by 
strongly  compressing  the  eye  with  the  half-closed  lids,  and  liringing 
the  object  close  towards  one  or  other  side  of  the  eye,  generally 
toward  the  temporal,  the  patient  is  sometimes  able  even  to  read. 
Beyond  two  or  three  inches,  vision  becomes  very  indistinct,  and 
at  a  few  feet,  the  patient,  in  general,  can  judge  neither  of  the  dis- 
tance nor  form  of  objects,  so  that  he  is  rendered  nearly  as  dependent 
as  if  he  were  totally  blind. 

One  of  Mr.  Wardrop's,  patients,  with  conical  cornea,  observed  that 
when  she  looked  at  a  luminous  body  at  a  distance,  such  as  a 
candle,  it  was  multiplied  five  or  six  times,  and  that  all  the  images 
were  more  or  less  indistinct.*  This,  I  beheve,  is  generally  the  case 
in  conical  cornea.  When  Dr.  Brewster  examined  the  eye  of  Mr. 
Wardrop's  patient,  he  observed,  that  in  every  aspect  in  which  the 
cornea  could  be  viewed,  its  section  appeared  to  be  a  regular  curve, 
increasing  in  curvature  towards  the  vertex ;  a  form,  he  remarks, 
which  could  produce  no  derangement  in  the  refraction  of  the  incident 
rays.  As  the  disease  was  evidently  seated  in  the  cornea  which 
projected  to  an  unnatural  distance,  it  did  not  seem  probable  that 
there  was  any  defect  in  the  structure  of  the  crystalline  lens.  He 
was,  therefore,  led  to  believe,  that  the  broken  and  indistinct  images 
which  appeared  to  encircle  luminous  objects,  arose  from  some  emi- 
nences on  the  cornea,  which  could  not  be  detected  by  a  lateral 
view  of  the  eye,  but  which  might  be  rendered  visible  by  the  changes 
which  they  induced  upon  the  image  of  a  luminous  object  that  was 
made  to  traverse  the  surface  of  the  cornea.  He,  therefore,  held  a 
candle  at  the  distance  of  fifteen  inches  from  the  cornea,  and  keeping 
his  eye  in  the  direction  of  the  reflected  rays,  observed  the  variations 
in  the  size  and  form  of  the  image  of  the  candle.  The  reflected 
image  regularly  decreased  when  it  passed  over  the  most  convex 
parts  of  the  cornea  ;  but  when  it  came  to  the  part  nearest  the  nose, 
it  alternately  expanded  and  contracted,  and  sutfered  such  derange- 
ments as  to  indicate  the  presence  of  a  number  of  spherical  eminences 
and  depressions,  which  sufficiently  accounted  for  the  broken  and 
multiplied  images  of  luminous  objects.  Mr.  Wardrop  states,  that 
Dr.  Brewster  had  afterwards  examined  a  great  variety  of  cases  of 
conical  cornea  ;  and  that  in  all  of  them,  without  exception,  he  had 
detected  inequalities  in  the  superficial  conformation  of  the  cornea. 

It  does  not  appear  to  have  been  yet  ascertained  by  dissection; 
whether  the  cornea  in  this  disease  is  merely  protruded  into  the 
conical  form  which  it  assumes,  or  actually  thickened,  so  that  the 
cone  is  solid.  The  external  appearance  would  certainly  lead  us 
to  think  that  the  latter  was  the  case  ;  and  accordingly  Sir  WiUiam 
Adams  has  described  this  disease  as  a  morbid  thickening  and 
growth  of  the  substance  of  the  cornea. f  Mr.  Wardrop,  however, 
states  that  the  irregular  portion  at  the  apex  of  the  protrusion  which 

*  Morbid  Anatomy  of  the  Human  Eye.     Vol.  i.  p  131.  London,  1819. 
t  Journal  of  Science  and  the  Arts.    Vol  ii.  p.  403.    London.    1817. 


439 

is  sometimes  clouded  and  opaque,  is  generally  very  thin  ;  and  that 
in  one  case,  a  gentleman  with  this  disease  receiving  a  blow  on  the 
eye,  the  cornea  burst. 

This  disease  generally  begins  first  in  one  eye,  and  after  a  time 
attacks  the  other  also.  It  has  been  met  with  in  almost  every  stage 
of  life  :  like  common  short-sightedness,  it  appears  most  frequently 
about  the  time  of  puberty,  or  at  least  advances  rapidly  about  that 
period.  In  one  instance,  Mr.  Wardrop  met  with  it  in  a  boy  of 
eight  years  of  age.  Sir  W.  Adams  had  seen  it  in  patients  from  16 
to  70 ;  much  more  frequently,  however,  in  women  than  in  men, 
and  in  young  tban  in  old  persons. 

The  progress  of  this  disease  is  unattended  by  inflammation, 
pain,  or  feeling  of  distension.  It  is  not  likely  that  it  depends  on 
any  pressure  of  the  aqueous  humour.  More  probably  it  is  an 
effect  of  some  inordinate  or  irregular  action  of  the  nutrient  vessels 
of  the  cornea  itself 

Treatment.  It  is  generally  agreed  that  evacution  of  the  aqueous 
humour  is  of  no  use  in  this  disease.  Pressure,  astringents,  and  all 
other  local  means,  appear  also  to  have  failed  in  arresting  its  pro- 
gress. 

Mr.  Travers  says  he  has  found  repeated  blisters,  and  the  more 
powerful  tonics,  as  steel  or  arsenic,  decidedly  serviceable.*  As  it  is 
evident,  however,  that  he  confounds  conical  cornea  with  aqueous 
dropsy,t  it  is  impossible  to  know  whether  the  benefit  accruing  from 
these  remedies  occurred  in  the  former,  the  latter,  or  both  of  these 
diseases. 

The  same  author  states,  that  the  confusedness  of  vision  is  greatly 
lessened  by  the  patient's  looking  through  an  opening  of  the  size 
of  the  pupil,  formed  in  a  piece  of  black  wood,  and  of  about  a  quarter 
of  an  inch  or  more  in  depth.  This  affords  more  aid  in  correcting 
vision  than  any  form  of  lens.  Indeed,  notwithstanding  Dr. 
Brewster's  opinion,  that  the  injuiious  effects  of  this  disease  upon 
vision  may,  within  certain  limits,  be  removed  by  glasses,  and  by 
preventing  the  image  from  being  formed  by  rays  passing  through 
any  part  of  the  corrugated  surface  of  the  cornea,  such  as  he  dis- 
covered in  Mr.  Wardrop's  case,  I  have  never  learned  that  any 
patient  has  actually  derived  the  slightest  benefit  from  concave  or 
other  glasses. 

Sir  W.  Adams,  from  the  opinion  which  he  had  adopted,  that 
the  conical  form  assumed  in  this  disease  was  the  effect  of  a  morbid 
growth  of  the  cornea,  and  that  the  short  sight  of  the  patient  was 
to  be  attributed  to  the  increased  refractive  power  of  the  part,  which, 
together  with  that  of  the  crystaUin^  lens,  brought  the  rays  of  light 
to  a  point  far  short  of  the  retina,  suggested,  that  as  it  was  impos- 
sible to  remove  the  morbid  state  of  the  cornea,  without  rendering 
it  unfit  for  the  transmission  of  hght,  a  useful  degree  of  vision  might 

*  Synopsis  of  the  Diseases  of  the  Eye,  p.  286.    London,  1820.    +  Ibidem,  p.  124. 


440 

be  restored  by  removal  of  the  crystalline  lens.  His  opinion  in 
favour  of  this  plan  was  confirmed  by  what  happened  in  the  case 
of  a  woman  of  nearly  seventy  years  of  age,  vviio  placed  herself 
under  his  care,  labouring  under  this  disease  accompanied  with 
cataracts.  These  he  successfully  removed,  and  had  the  gratifica- 
tion to  find  that  the  patient  was  capable  of  seeing  much  more  dis- 
tinctly without  convex  glasses  than  it  is  usual  for  those  to  do  who 
have  undergone  the  operation  for  cataract. 

The  favourable  result  of  this  case  determined  him,  at  the  earliest 
opportunity,  to  try  the  effect  of  removing  the  crystalline  lens,  as  a 
remedy  for  blindness  produced  by  conical  cornea.  A  favourable 
case  presented  itself  the  following  year,  in  a  young  woman,  who, 
during  six  years  had  found  her  sight  gradually  decreasing,  and  at 
the  expiration  of  that  period,  became  so  blind,  from  this  disease,  as 
to  be  unable  to  continue  her  employment  as  a  servant.  The 
cornea  of  each  eye  had  assumed  the  conical  form  in  a  great  degree, 
attended  b}^  a  slight  opacity  in  the  apex  of  each  cone,  but  none 
whatever  in  the  crystalline  lens.  She  could  walk  without  a  guide, 
and  could  see  at  the  distance  of  three  or  four  feet,  so  as  to  avoid 
running  against  any  person,  but  had  entirely  lost  the  power  of 
reading  or  perceiving  minute  objects,  however  near  to  the  eyes. 
Sir  William  effected  the  removal  of  the  crystalline  lens  of  one  of 
her  eyes,  by  the  operation  of  division.  The  patient,  however,  re- 
turned to  the  country  before  the  eye  had  entirely  recovered  from 
the  operation,  and  Sir  William  did  not  again  sfee  her  until  nearly 
twelve  months  afterwards,  when  he  was  in  the  highest  degree 
gratified  to  find  her  capable  of  discovering  minute  objects,  and 
reading  the  smallest  sized  print,  without  the  assistance  of  a  glass, 
while  holding  the  book  at  the  usual  distance  of  ten  or  twelve  inches 
from  the  eye.  The  usual  cataract  spectacles  for  near  objects,  of 
two  inches  and  a  half  focus,  confused  her  sight  nearly  in  the  same 
manner  as  it  had  been  before  the  crystalline  lens  was  removed, 
while  with  those  of  nine  or  ten  inches  focus,  her  capability  of  seeing 
minute  objects  was  somewhat  improved.  Objects  at  a  distance  she 
saw  better  without  than  with  any  glass  which  could  be  found. 

I  am  ignorant  whether  the  plan  of  obviating  the  effects  of  con- 
ical cornea,  by  removal  of  the  crystalline  lens,  has  been  tried  by 
any  other  oculist. 


SECTION  II. HYDROPHTHALMIA.  OR  DROPSY  OF  THE  EYE. 

Dropsical  affections  of  the  eyeball  sometimes  depend  entirely  on 
local  causes ;  in  other  cases,  they  are  connected  with  some  cachec- 
tic state  of  the  system,  as  the  scrofulous,  or  that  which  attends 
chlorosis.  Rarely  does  it  happen  that  hydrophthalmia  either  forms 
part  of  a  general  dropsy,  or  is  combined,  in  point  of  origin,  with 
any  other  local  dropsical  affection. 


441 


1.  Dropsy  of  the  Aqueous  Humour 

Is  the  most  common  variety  of  hydrophthalmia.  Following  an 
injury  of  the  eye,  or  of  the  surrounding  parts,  (blows,  for  example, 
on  the  edge  of  the  orbit,  or  lacerated  wounds  of  the  eyelid  and 
eyebrow),  it  is  generally  hmited  in  its  extent,  and  combined  with 
a  paralytic  and  tremulous  state  of  the  iris,  and  partial  amaurosis. 
But  when  constitutional  in  its  origin,  it  sometimes  proceeds  till  the 
anterior  chamber  is  greatly  dilated. 

Symj^toms.  1,  At  first,  the  cornea  is  merely  more  prominent 
than  natural,  but  after  a  time,  it  evidently  increases  in  diameter. 
This  increase  may  even  go  on  till  the  cornea  is  twice,  thrice,  or 
four  times  its  natural  size,  before  it  bursts,  and  before  it  loses  much 
of  its  transparency.  It  always  appears  in  advanced  cases  a  little 
cloudy. 

2.  The  iris  loses  its  motion,  even  from  the  commencement  of 
the  disease,  and  always  appears  darker  than  it  should  be.  The 
pupil  is  generally  in  the  middle  state  between  contraction  and  dila- 
tation. In  some  cases,  its  edge  is  bent  back  towards  the  lens,  so 
that  the  iris  presents  the  form  of  a  funnel. 

3.  The  patient  complains  of  pressure  and  distension  in  the  eye  ; 
scarcely  ever  of  pain. 

4.  In  the  commencement,  the  eye  is  unnaturally  far-sighted, 
but  this  changes  into  an  amaurotic  weakness  of  sight,  never  reach- 
ing to  complete  blindness. 

5.  The  motions  of  the  eye  are  performed  with  more  and  more 
difficulty,  in  proportion  as  it  increases  in  size.  It  at  the  same  time 
becomes  harder  to  the  feeling,  and  the  sclerotica,  necessarily  forced 
to  partake  in  the  extension  of  the  cornea  becomes  thin,  and  blue, 
as  in  young  children. 

Causes.  Except  when  this  disease  results  from  such  injuries  as 
have  already  been  mentioned,  its  causes  are  obscure.  The  sudden 
suppression  of  cutaneous  eruptions  has  been  mentioned  as  a  cause. 

Prognosis.  Arising  from  any  cachexia,  this  disease  is  apt  to 
degenerate  into  general  dropsy  of  the  eye.  When  it  originates  in 
any  more  limited  cause,  as  an  injury,  or  the  suppression  of  an  erup- 
tion, it  never  has  been  observed  to  go  the  length  of  bursting  the 
cornea,  and  may  frequently  be  cured. 

Treatment.  1.  When  this  affection  of  the  aqueous  humour  is 
the  result  of  an  injury,  much  advantage  will  be  derived  from  a  suc- 
cession of  blisters  to  the  temple,  and  behind  the  ear  ;  and  from  the 
use  of  mercury  combined  with  purgatives. 

2.  When  this  disease  forms  part  of  a  general  dropsical  affection, 
or  appears  to  depend  on  the  same  cause  as  any  other  local  dropsy 
present  at  the  same  time,  diuretics  may  be  employed  with  some 
hope  of  success.  In  other  cases  of  hydrophthalmia,  they  are  of  no 
avail. 

3.  If  the  suppression  of  an  eruption,  especially  one  to  which  the 

56 


442 

patient  has  long  been  subject,  and  which  has  been  attended  by  a 
discharge,  be  tlie  suspected  cause,  the  "xcitement  of  an  artificial 
eruption,  by  friction  with  tartar  emetic  ointment,  is  plainly  indicated. 

4.  In  the  incipient  stage,  and  especially  when  the  disease  is  of 
local  origin,  friction  round  the  eye  with  mercurial  ointment  has 
been  found  useful. 

5.  If  the  disease  is  advanced,  and  vision  much  affected,  but  the 
sclerotica  not  yet  aiscoloured  from  partaking  in  the  distension  and 
extenuation  of  the  front  of  the  eye,  paracentesis  oculi  ought  to  be 
employed.  An  incision  may  be  made  at  the  low^er  part  of  the  cor- 
nea, two  lines  long,  and  at  the  distance  of  half  a  line  from  the 
sclerotica.  Beer  recommends,  not  merely  that  an  evacuation  of  the 
aqueous  humour  should  be  made  in  this  way,  buu  that  the  wound 
should  be  re-opened  every  day,  for  a  number  of  successive  days,  or 
even  w^eeks,  so  that  the  aqueous  cavities  may  be  maintained  in  a 
void  state.  More  than  once,  he  had  observed  general  remedies  to 
have  a  good  effect  after  this  operation,  although  they  had  had  none 
before.  If  it  is  not  successful  in  curing  the  disease,  it  proves  at  least 
an  excellent  palliative  ;  and  if  too  large  an  opening  is  not  made, 
may  be  frequently  repeated  with  temporary  advantage. 

2.  Sub-Sclerotic  Dropsy. 

As  the  internal  surface  of  the  sclerotica  is  connected  by  fine  cel- 
ular  membrane  to  the  external  surface  of  the  choroid,  and  as  nu- 
merous vessels  and  nerves  pass  bet^veen  these  tunics,  it  is  evidently 
incorrect  to  talk  of  any  serous  cavity  existing  betw^een  them.  Thin 
fluid,  however,  may  accumulate  there,  constituting  what  we  may 
term  sub-sclerotic  hydrophthalmia. 

The  symptoms  of  this  disease  wHll  in  some  respects  resemble 
those  arising  from  a  dropsical  effusion  betv/een  the  choroid  and  the 
retina  ;  and  will,  like  them,  derive  relief  from  the  operation  of  punc- 
turing the  eye,  and  allowing  the  collected  fluid  to  escape. 

3.  Suh-Choi^oid  Dropsy. 

I  have  already*  had  occasion  to  state,  that  a  Avatery  effusion  be- 
tween the  choroid  and  the  retina,  is  by  no  means  an  uncommon 
result  of  inflammation  of  the  former  of  these  membranes.  I  need 
not  repeat  what  I  have  said  regarding  the  symptoms  of  choroiditis, 
which  in  general  will  be  found  to  have  preceded,  or  to  accompany, 
sub-choroid  h yd roph th almia. 

Examples  cf  this  disease,  in  which  it  had  proceeded  so  far  as  to 
cause  the  absorption  of  the  vitreous  humour,  and  the  compression 
of  the  retina  into  a  cord  extending  from  the  optic  nerve  to  the  back 
of  the  lens,  have  now  been  described  by  many  observers.!     The 

t  See  page  382. 

t  Zinn,  Descriptio  Anatomica  Oculi  Humani,  p.  25,  Gottingse,  1780. — Scarpa  delle 
Malattie  degli  Occhi,  Vol.  ii.  p.  172.  Pavia,  1816. — Ware's  Observations  on  the 
TreatrL-^nt  of  the  Epiphora,  &c.  p.  284,  London,  1818. — ^Wardrop's  Morbid  Anatomy 
of  the  Human  Eye.     Vol.  ii.  p.  65.     London,  1818. 


443 

progress  of  the  dropsical  effusion,  and  the  symptoms  by  which  it  is 
accompanied,  are  by  no  means  ahke  in  all  cases.  When  the  ac- 
cumulation takes  place  ;^lowly,  the  loss  of  vision  is  gradual,  and  the 
attending  pain  and  redness  are  not  severe.  In  other  cases,  the 
water  is  collected  quickly,  and  is  accompanied  with  great  pain  in 
both  the  eye  and  head ;  the  choroid,  pressing  against  the  sclerotica, 
produces  the  extenuation  of  the  latter,  while  the  eyeball  undergoes 
either  a  general  or  partial  enlargement ;  the  pupil  becomes  dilated 
and  sometimes  displaced  ;  and  when  the  disease  is  far  advanced, 
there  appears  an  opaque  body  behind  the  pupil,  which  is  nothing 
else  than  the  retina  compressed  into  a  cone,  the  apex  of  which  is  at 
the  entrance  of  the  optic  nerve,  while  the  basis  surrounds  the  crys- 
talline lens.  Mr.  Wardrop  mentions,  that  in  one  instance  this  ap- 
pearance was  mistaken  for  cataract,  and  an  attempt  made  to  couch 
it ;  a  fruitless  operation  which  gave  great  pain.* 

Treatment.  In  suspected  cases  of  sub-choroid  hydrophthalmia, 
there  can  be  no  doubt  of  the  propriety  of  following  the  practice  of 
Mr.  Ware,  and  puncturing  the  eye  at  the  usual  place  of  passing 
the  cataract  needle  through  the  sclerotica  and  choroid.  Mr.  "W. 
recommended  a  grooved  needle  for  this  purpose,  so  that  the  fluid 
contained  between  the  sclerotica  and  choroid  might  more  certainly- 
escape.  Care  must  be  taken  in  making  the  puncture,  to  direct 
the  point  of  the  instrument,  so  that  it  may  not  wound  the  poste- 
rior part  of  the  crystalline  capsule.  The  operation  may  be  re- 
peated from  time  to  time  should  the  symptoms  seem  to  demand  it. 

The  first  case  related  by  Mr.  Ware,  affords  a  good  example  both 
of  the  disease  and  of  the  relief  afforded  by  paracentesis.  The  pa- 
tient, a  lady  of  about  45  years  of  age,  perceived  first  of  all  a  dimness 
in  her  left  eye,  the  cause  ot  which  she  was  not  able  to  assign.  She 
supposed  it  to  have  been  the  consequence  either  of  taking  cold,  or 
of  the  cessation  of  a  discharge  from  one  of  her  legs,  to  which  she 
had  been  subject  for  a  considerable  time.  The  dimness  was  dis- 
covered accidentally,  on  her  attempting  to  see  an  object  with  the 
left  eye  whilst  the  right  was  shut,  and  in  a  short  time  the  sight  af- 
forded by  that  eye  rendered  her  no  assistance ;  objects  when  placed 
straight  before  her  being  invisible,  and  their  appearance,  when  re- 
moved to  the  outer  side  of  the  axis  of  vision  being  obscure,  and 
indistinct.  The  eye  had  not  altered  its  apoeaiance  in  any  respect, 
the  pupil  being  neither  cloudy  nor  dilated.  In  December  1804, 
about  two  years  after  the  dimness  was  first  perceived,  she  began  to 
feel  pain  in  the  eye,  and  it  became  slightly  inflamed.  Although 
the  inflammation  never  appeared  to  be  considerable,  the  pain  rapid- 
ly increased  to  a  most  violent  height,  affecting,  in  a  few  days,  both 
the  eye  and  the  head,  and  proving  particularly  severe  during  the 
night.  The  pupil,  now  for  the  first  time,  became  dilated,  and  had 
a  misty  appearance  ;  but  the  degree  of  opacity  was  very  insufficient 
to  account  for  the  total  loss  of  sight. 

*  Morbid  Anatomy  of  the  Human  Eye.     Vol.  ii.  pp.  67,  274.     London,  1818. 


444 

Leeches,  blisters,  fomentations  \vith  poppy  heads,  and  a  free  use 
of  opium  internally,  were  repeatedly  tried,  but  did  not  afford  any 
relief  The  internal  employment  of  the  muriate  of  mercury  was 
equally  ineffectual.  The  progress  of  the  disorder,  and  the  state  of 
the  patient  at  this  period,  closely  resembling  those  of  another  pa- 
tient, in  whose  eye,  after  death,  Mr.  Ware  had  found  a  sub-choroid 
collection  of  thin  fluid,  with  coarctation  of  the  retina,  led  him  to 
think  that  the  violent  pain  which  this  lady  suffered  might  depend 
on  a  similar  state  of  the  eye.  It  also  occurred  to  him  that  if  the 
effused  fluid  could  be  discharged,  it  might  be  a  means  of  affording 
relief  The  operation  seemed  neither  impracticable  nor  difficult, 
and  the  patient  readily  acceded  to  submit  to  it,  as  indeed  she  would 
have  done  to  any  operation,  whatever  might  have  been  its  hazard, 
so  extreme  was  the  pain  she  at  that  time  endured.  Mr.  Ware  in- 
troduced a  common  spear-pointed  couching  needle  through  the  scle- 
rotica, a  littleforther  back  than  where  it  is  usually  introduced  for  the 
purpose  of  depressing  a  cataract.  As  soon  as  the  instrument  entered 
the  eye,  a  yellow  fluid  immediately  escaped,  sufficient  in  quantity 
to  wet  a  common  handkerchief  quite  through.  The  needle  was 
kept  in  the  eye  about  a  minute,  in  order  to  afford  the  fluid  a  more 
ready  exit :  and  as  soon  as  it  was  withdrawn,  the  discharge  ceased. 
The  tension  of  the  eye  was  considerably  diminished  by  the  ope- 
ration. A  compress  dipped  in  a  saturnine  lotion  was  bound  upon 
it,  and  the  patient  put  to  bed.  She  continued  in  pain  about  ten 
minutes,  but  then  fell  into  a  sound  sleep,  which  lasted  upwards  of 
two  hours  ;  and  on  awaking,  her  eye  was  quite  easy.  The  compress 
was  again  moistened  with  suturnine  lotion,  and  she  took  some  nour- 
ishment. She  passed  the  next  night  very  comfortably,  without  the 
assistance  of  laudanum,  although  previously  it  had  been  given  her 
in  large  doses.  The  same  application  was  continued  to  the  eye, 
which  afterwards  remained  perfectly  easy,  with  scarcely  any  ap- 
pearance of  inflammation.  The  pupil  continued  delated,  but  did 
not  become  opaque.  About  three  weeks  after  the  operation,  the 
patient  caught  a  cold,  and  complained  that  the  eye  felt  more  ten- 
der than  usual.  Mr.  W.  was  alarmed  lest  a  fluid  might  again  be 
effused  in  the  old  place,  and  the  pain  return  ;  but  this  was  happily 
prevented  by  the  application  of  a  blister  on  the  side  of  the  head. 

4.  Dropsy  of  the  Vitreous  Humour. 

Beer  has  described  this  disease  as  characterised  by  the  following 
symptoms. 

1.  An  increase  of  size,  chiefly  in  the  posterior  part  of  the  eyeball ; 
the  eye  assuming  the  form  of  a  cone,  the  cornea  being  pushed 
forwards  without  undergoing  any  other  change. 

2.  The  aqueous  humour  diminished  m  quantity,  and  the  iris 

•  Remark  on  the  Ophthalmy,  &c.  p.  233.  London,  1814.  See  also  Ware's  Ob- 
servations on  the  Cataract,  and  Gutta  Serena ;  p.  443.     London,  1812. 


445 

pushed  forwards  into  contact  with  the  cornea  ;  the  iris  not  changed 
in  colour,  nor  the  pupil  extremely  dilated. 

3.  The  sclerotica  from  distension  assumes  a  deep  blue  colour. 

4.  At  first,  short-sightedness,  soon  followed  by  weakness  of  sight, 
and  then  by  complete  amaurosis,  so  that  not  even  the  least  sensi- 
hility  to  hght  remains. 

5.  The  movements  of  the  eye  are  much  sooner  impeded  than  in 
aqueous  dropsy.  The  eye  becomes  extremely  hard,  and  altogether 
motionless. 

6.  There  is  pain  in  the  eye  from  the  very  commencement.  It 
daily  increases  in  violence,  and  spreads  to  the  half  of  the  head,  to 
the  teeth,  and  to  the  neck.  At  last  the  patient  becomes  almost 
mad  with  the  pain,  and  calls  upon  the  surgeon  to  evacuate  the 
contents  of  the  eye.  Beer  saw  a  man  who  did  this  for  himself 
with  his  penknife.  Even  when  the  pain  is  comparatively  mode- 
rate, the  patient's  sleep  and  appetite  entirely  fail. 

7.  Allowed  to  go  on  without  interruption,  the  enlarged  eyeball 
presses  upon  the  walls  of  the  orbit,  and  induces  caries. 

Causes.  These  are  equally  obscure  as  those  of  the  dropsy  of 
the  aqueous  humour.  The  scrofulous  or  syphilitic  cachexia  is 
blamed,  or  a  union  of  both  is  sometimes  suspected. 

Treatment.  General  remedies  may  be  directed  against  the 
particular  cause  which  is  supposed  to  give  rise  to  the  disease ;  but 
most  relief  is  derived  from  diminishing  the  quantity  of  the  vitreous 
humour.  This  may  be  attempted  by  puncturing  the  sclerotica 
and  choroid,  as  in  cases  of  sub-choroid  dropsy.  Should  this  fail, 
the  mode  recommended  by  Beer  will  require  to  be  adopted  ;  name- 
ly, to  make  a  section  of  the  cornea,  as  in  the  operation  of  extrac- 
tion, and  evacuate  the  lens  and  part  or  the  whole  of  the  vitreous 
humour,  after  which  the  coats  of  the  eye  gradually  shrink  to  a 
small  size. 

5.   General  Hydr ophthalmia. 

Both  the  aqueous  and  the  vitreous  humour  may  be  increased  in 
quantity  at  the  same  time,  so  that  the  whole  eye  is  greatly  en- 
larged, in  which  state  the  name  hwphthalmos  has  been  bestowed 
on  it,  from  its  resemblance  to  the  eye  of  an  ox. 

This  disease  presents  a  union  of  the  symptoms  of  the  first  and 
fourth  varieties  of  Hydrophthalmia,  as  far  as  they  can  co-exist. 
The  pain  is  excessive.  The  motion  of  the  eye  is  lost.  The  pa- 
tient is  deprived  of  sleep,  appetite  for  food,  and  at  last  even  of 
reason.  Caries  of  the  orbit  takes  place,  if  the  case  is  neglected  ; 
and  the  patient  dies,  worn  out  by  fever,  before  the  eye  gives  way. 

Beer  had  met  with  this  disease  only  in  extremely  cachectic,  and 
especially  scrofulous  and  scorbutic  subjects. 

Evacuation  of  the  contents  of  the  eye  must  be  had  recourse  to, 
as  in  the  vitreous  hydrophthalmia  ;  or,  if  the  eye  be  disorganized 
by  inflammation,  as  well  as  enlarged  by  dropsy,  it  may  with  pro- 
priety be  extirpated. 


446 


SECTION  III. SANGUINEOUS  EFFUSION  INTO  THE  EYE.  , 

Effusion  of  blood  into  the  aqueous  chambers  frequently  follows 
a  blow  on  the  eye.  iSmaller  quantities  of  blood  are  sometimes 
seen  to  accompany  hypopium,  especially  that  which  arises  from 
the  bursting  of  an  abscess  of  the  iris.  Wounds  of  the  iris  are  gen- 
erally attended  by  a  discharge  of  red  blood  ;  and  the  same  is  ob- 
served when  the  iris  is  torn  from  the  choroid,  either  accidentally  or 
for  the  purpose  of  forming  an  artificial  pupil.  Blood  is  also  occa- 
sionally effused  into  the  substance  of  the  cornea,  in  consequence  of 
inflammation. 

To  such  cases  as  these,  I  do  not  mean  at  present  to  direct  the 
attention  of  the  reader  ;  but  to  an  internal  haemorrhage  of  the  ej'e, 
which  appears  neither  to  arise  from  injury,  nor  to  depend  altogether 
on  inflammation,  and  which  sometimes  has  been  spoken  of  under 
the  name  of  apoplexy  of  the  eye. 

As  the  recorded  instances  of  this  disease  are  ver}^  few  in  num- 
ber, 1  shall  quote  two  of  the  most  interesting  of  them.  They  will 
serve  to  illustrate  the  symptoms  of  this  remarkable  affection  much 
more  completely  than  I  could  pretend  to  do  by  any  general  des- 
cription. 

The  first  case  w^iich  I  shall  quote  is  by  Mr.  John  Bell,  and 
affords  an  example  of  this  disease  occuning  in  an  eye  previously 
healthy. 

"  Mr.  A .  though  not  yet  twenty  years  of  age,  is  more  than 

six  feet  high  ;  and  three  j^ears  ago^  when  first  he  was  struck  with 
this  singular  kind  of  iDlindness,  was  growing  so  rapidly,  that  he 
actually  believes  he  gained  five  inches  in  the  year.  He  was  then 
a  stripling,  and  is  now  tall,  slender,  and  delicate  in  his  constitution, 
though  remarkably  well  formed,  and  destined  to  become  a  strong 
and  muscular  man.  Early  in  the  month  of  September,  1803,  on 
the  day  in  which  he  wms  first  attacked  with  this  blindness,  he 
had  his  hair  cut  early  in  the  morning,  he  ate  very  heartil)^  a  hurried 
dinner,  when,  a  companion  having  called  while  he  was  yet  at 
table,  and  proposed  a  party  in  a  house  at  some  distance,  he  went 
with  him,  and,  being  mere  lads,  and  in  a  playful  humour,  his 
friend  ran,  and  he  pursued  at  full  speed,  for  the  space  of  three  or 
four  liuudred  yards  ;  he  instantly  was  sensible  of  his  sight  being 
dim,  in  the  left  eye  :  he  disregarded  at  first  a  feeling  which  he 
imagined  to  be  temporary,  but,  having  arrived  at  the  house,  and 
sat  down,  he  was  alarmed  to  find  his  vision  still  more  obscure, 
and,  turning  round  to  those  who  were  in  company,  he  asked 
whether  they  perceived  any  thing  wrong  in  his  eye ;  they  said 
there  was  blood  upon  it ;  upon  looking  into  a  mirror  he  saw  the 
blood,  found  himself  totally  blind  of  the  left  eye,  was  assailed 
with  dreadful  pain  :  the  bloody  effusion  took  place,  the  blood  be- 
came visible,  and  the  vision  was  entirely  obscured  in  the  short 
space  of  fifteen  minutes  ;  then   the  violent  pain  began,  a  conse- 


447 

quence  plainly,  and  not  a  cause  of  the  blindness,  and  for  ten  days 
he  continued  entirely  blind  of  that  eye. 

"  His  vision  was  gradually  restored,  by  the  blood  which  had 
filled  the  whole  of  the  anterior  chamber  of  the  eye,  subsiding  below 
the  level  of  the  pupil :  the  blood  was  still  visible  in  the  lower  part 
of  the  eye,  and  continued  so  for  three  weeks  ;  it  gradually  van- 
ished, and  the  eye  recovered  its  wonted  appearance,  except  that, 
in  the  very  lowest  part,  under  the  level  of  the  pupil,  there  remained 
a  little  white  matter,  viz.  the  gluten  of  the  effused  blood.  Such 
was  the  first  attack  of  the  disorder,  from  which  he  continued  free 
for  the  space  of  six  months. 

"In  the  month  of  May,  1804,  one  evening  while  sitting  at  sup- 
per, not  conscious  of  any  previous  excitement,  from  violent  exercise 
or  exposure  to  heat,  but  probably  affected  by  the  supper,  wine, 
light,  and  heat,  and  animated  conversation,  he  suddenly  perceived 
the  obscurity  coming  over  his  vision,  the  blood  again  appeared  in 
the  chamber  of  the  eye,  which  was  next  morning  affected  with 
violent  pain :  yet  this  was  in  all  respects  a  less  severe  paroxysm 
than  the  first. 

"  Little  more  than  a  month  had  elapsed,  when  having,  in  the 
warm  month  of  June,  gone  into  the  river  to  bathe,  he  was  in  the 
act  of  swimming,  and  just  when  coming  out  of  the  water,  struck 
with  this  obscurity  of  vision.  The  blood  instantly  came  over  his 
eye,  which,  on  the  ensuing  day  was  affected  with  most  excruci- 
ating pain,  extending  to  the  temple  ;  but  in  three  weeks  or  a  moni  h, 
his  sight  was  completely  restored,  and  the  eye  had  recovered  its 
natural  splendour  and  cleanness.  In  the  end  of  September,  or 
beginning  of  October,  he  was  again  attacked,  though  he  was  con- 
scious of  no  excess,  ^nd  was  quiet,  regular,  and  discreet  in  his 
way  of  living  ;  he  was  seized  while  writing,  and  recollects  no  sen- 
sible cause  to  which  the  paroxysm  could  be  ascribed,  unless  it 
were  to  the  hanging  of  the  head  and  straining  of  the  eye.  The 
sight  was  obscured,  the  blood  appeared  again  in  the  chamber  of  the 
eye,  the  pain  returned,  the  blood  was  absorbed  again  within  the 
usual  period,  and  the  sight  was  in  course  restored. 

"  It  was  on  the  first  of  November,  in  walking  across  the  bridge 
at  night,  betwixt  ten  and  eleven  o'clock,  that  he  sustained  the 
fourth  attack,  but  without  such  total  loss  of  vision,  or  so  much 
effusion  of  blood  as  heretofore,  and  certainly  the  blood  was  not  so 
long  of  being  absorbed,  nor  was  he  so  long  obliged  to  cover  the  eye 
from  the  light :  in  eight  or  ten  days  he  was  able  to  uncover  the 
eye,  the  appearance  of  suffusion  of  blood  was  gone,  but  the  lym- 
phatic coagulum,  occupying  the  anterior  chamber  of  the  eye,  was 
manifestly  accumulating.  On  the  3d  of  February,  1805,  he  had 
a  like  paroxysm,  arising  from  very  obvious  causes  ;  being  a  day  of 
election  of  Member  of  Parliament  for  this  city,  his  regiment  was 
marched  out  of  town  to  the  distance  of  eighteen  miles  ;  and  both 
in  matching  out  to  the  temporary  quarters  allotted  for  his  regiment, 


448 

and  in  returning,  he  walked  along  with  the  men,  was  greatly 
heated  by  the  exercise,  and  very  naturally  refers  this  attack  to  a 
cause  so  expressly  resembling  that  which  first  gave  rise  to  his 
malady,  that  it  could  not  fail  to  attract  his  particidar  notice. 
'  From  this  time.'  says  Mr.  A ,  '  these  paroxysms  became  pe- 
riodical, and  seemingly  spontaneous ;  they  returned  once  a  month, 
the  eye  was  kept  in  a  state  of  constant  irritability  and  frequent 
pain,  so  that  I  was  forced  to  have  it  constantly  covered  from  the 
light ;  5'et  no  circumspection  in  this  respect,  nor  in  my  habits  of 
living  seemed  to  avail  me. 

'• '  Of  the  few  paroxysms  which  I  am  able  to  particularize,  as  aris- 
ing from  any  obvious  excitement,  one  was  on  the  morning  after  our 
review,  in  the  month  of  August  last,  when,  after  being  in  the  field, 
we  sat  down  to  a  dinner  of  ceremony,  and  drank  late  ;  I  must  have 
exceeded,  but  am  not  conscious  of  having  been  intemperate  ;  I  went 
to  bed,  perhaps  a  little  heated  with  wine,  I  rose  earl}^  in  the  moi'n- 
ing  to  go  upon  guard,  and,  in  the  act  of  dressing,  and  especially  in 
stooping  to  wash  my  face,  1  Avas  sensible  on  the  instant  of  the  effu- 
sion of  blood,  and  the  return  of  the  blindness.'  The  second  memo- 
rable occasion  was  still  more  particular  in  the  circumstances,  the 
excitement  more  marked  than  any,  and  explaining  all  of  th€  others: 

Mr.  A had  gone  abroad  to  a  supper  party  of  young  people, 

where  a  most  unusual  degree  of  hilarity  prevailed,  some  very  ludi- 
crous songs  were  sung,  and  he  joined  the  general  mirth,  and  laughed 
immoderately,  and  so  long,  that  in  the  end  he  saw  the  candlea 
dim,  and,  in  a  moment,  found  his  eye  quite  suffused  with  blood. 

"  This  gentleman's  disease  has  now  taken  a  most  decided  form  ; 
it  returns  sometimes  once  a  fortnight,  sometimes  once  a  month, 
seldom  do  two  months  elapse  without  a  new  effusion  of  blood  ;  and 
it  returns  with  a  degree  of  regularity  almost  periodical.  The  sen- 
sibility of  the  eye  is  such,  that  he  is  obliged  to  keep  it  always  shad- 
ed ;  and  each  new  effusion  of  blood  is  now  followed  by  a  paroxysm 
of  pulsatory  pain  in  the  temple  of  the  side,  with  an  intolerable 
throbbing,  something  betwixt  general  headach,  and  pain  of  the 
affected  organ,  a  pain  v/hich  is  in  some  degree  relieved  by  steady 
and  continued  pressure.  Sometimes,  as  you  will  learn  from  the 
narrative,  the  excitement  is  sensible,  and  the  cause  of  it  such  as  in 
strict  prudence  he  should  have  avoided,  but  is  often  too  slight  to  be 
observed  ;  now  the  effusion  returns  always,  or  almost  always,  with- 
out an  express  or  sensible  cause,  from  a  predisposition  so  strong,  that 
he  is  come  to  a  conviction,  that  laughing,  crying,  singing,  running, 
swimming;  stooping,  excess  in  wnne,  or  any  of  those  causes  which 
have  at  former  times  plainly  produced  this  effusion,  would  cause  it 
instantly  to  return. 

"It  must  seem  very  surprising,  that  an  organ  so  delicate  as  the 
eye  should  be  able  thus  to  sustain  repeated  effusions  of  blood,  with- 
out having  its  structure  entirely  ruined ;  but  the  resistance  of  its 
strong  coats,  filled  and  tense  with  its  own  humours,  plainly  has  its 


449 

effect  in  limiting'  the  bloody  effusion,  yet  the  additional  tension  is 
such,  as  occasions  that  violent  pain  which  is  excruciating  even  on 
the  first,  and  at  its  acme,  the  second  day  after  the  effusion  has  taken 
place.  That  the  extravasation  is  of  pure  blood,  which  keeps  its 
properties  unaffected  by  the  dilution  with  the  aqueous  humour,  is 
both  sensible  to  sight,  and  proved  by  the  solid  white  coagulum,  which 
each  successive  effusion  leaves  behind.*  ******* 
Its  form  is  in  no  degree  changed ;  if  there  were  the  slightest  reason 
to  apprehend  any  alteration  of  bulk  or  form,  it  is  from  the  eyelid 
being  drawn  down,  and  that  somewhat  obliquely  over  the  eye,  so 
as  to  cover  much  of  the  cornea,  or  coloured  part,  and  exposing 
chiefly  the  inner  side  and  lower  part  of  the  eye,  where  the  coagulum 
lies.  The  blood  of  its  proper  purple  colour  obscures  the  whole  ;  the 
pupil  is  not  to  be  seen,  the  coagulum  which,  in  consequence  of  its 
bulk,  is  very  thinly  covered  with  the  blood,  is  almost  white,  and 
occupies  all  the  lower  part  of  the  anterior  chamber  of  the  aqueous 
humour,  and  the  space  betwixt  the  low^er  half  of  the  iris  and 
the  cornea,  covers  some  part  of  the  pupil,  and  has,  I  fear,  irremedia- 
bly injured  the  vision,  which  yet  is  not  extinct ;  but  strict  regimen, 
profuse  evacuations,  a  seton  in  the  nape  of  the  neck,  and  opiates  to 
appease  the  sensibility  of  the  eye ;  an  abstemious,  quiet,  and  regu- 
lated course  of  life,  will,  I  hope,  prevent  futui'e  effusions  ;  and  when 
his  growth  is  ascertained,  and  these  paroxysms  of  local  arterial  ac- 
tion are  abated,  I  hope  that  much  of  this  coagulum  will  be  ab- 
sorbed."* 

The  following  case,  communicated  by  Dr.  Houttuyn  of  Amster- 
dam, to  the  Royal  Academy  of  Sciences,  affords  an  instance  of  hae- 
morrhage, which,  although  not  expressly  stated  to  have  been  into 
the  cavities  of  the  eye,  I  presume  was  so,t  the  haemorrhage  being 
complicated  with  other  diseases  of  the  organ,  and  going  to  a  much 
greater  length  than  in  Mr.  Bell's  case. 

A  physician,  of  58  years  of  age,  originally  possessed  of  good  sight, 
but  which  had  become  somewhat  impaired  by  frequent  employment 
of  the  microscope,  was  surprised  one  morning,  on  getting  out  of  bed, 
to  find  that  he  scarcely  saw  any  thing  with  the  left  eye,  although 
he  felt  no  pain  in  it.  The  weakness  of  this  eye  continued  to  in- 
crease during  the  space  of  a  year  ;  at  last  it  ceased  entirely  to  per- 
form its  function,  without  any  thing  being  extraordinary  in  its  ap- 
pearance.    The  case  was  regarded  as  one  of  amaurosis. 

In  about  a  year  after  this,  the  eye.  appeared  to  be  affected  with 
a  kind  of  cataract,  which  formed  a  white  round  spot  in  the  pupil ; 
this  spot,  at  the  end  of  three  months,  changed  colour,  becoming 
yellowish,  and  then  of  a  bluish  green  ;  in  a  word,  it  assumed  the 
characters  of  glaucoma,  and  remained  in  that  state  during  two 
years  and  a  half,  without  the  patient  suffering  any  pain.     At  the 

*  Principles  of  Surgery,  "Vol.  iii.  p.  270.     London,  1808. 

t  Dr.  Voigtel  and  Mr.  Wardrop  have  come  to  the  same  conclusion  regarding  this 
case. 

57' 


450 

end  of  that  period,  and  towards  the  termination  of  the  month  of 
June,  while  occupied  in  his  garden,  gathering  hyacinth  roots,  with 
his  back  turned  towards  the  sun,  he  was  seized  with  inflammation 
in  the  diseased  eye.  From  this  he  soon  recovered  ;  but  some  days 
after,  he  felt  the  eye  suddenly  swell  up,  till  it  appeared  to  him  of 
the  size  of  a  hen's  egg.  This  sudden  distension,  the  exact  nature 
of  which  Dr.  Houttuyn  leaves  undecided,  was  accompanied  by 
acute  pain.  Some  drops  of  fluid,  which  the  patient  found  running 
from  the  nostril,  led  him  to  blow  his  nose,  which  occasioned  a 
dreadful  noise  in  the  head,  and  rendered  the  pain  of  the  eye  still 
more  severe.  At  the  same  moment  there  began  to  flow  from  the 
inner  canlhus  of  the  eye,  a  small  stream  of  blood ;  the  pain  then 
diminished,  and  soon  ceased  entirely ;  but  the  haemorrhage  con- 
tinued for  two  hours,  and  he  lost  from  five  to  six  ounces  of  blood. 
In  six  weeks  he  had  recovered  from  the  immediate  effects  of  this 
accident,  but  the  eye  had  shrunk  to  a  very  small  size.* 


SECTION  IV. FUNGOUS  EXCRESCENCE  OF  THE  IRIS. 

In  the  seventh,  eighth,  and  ninth  sections  of  Chapter  IV.  I  have 
described  certain  excres'cences  and  tumours  of  the  membrane  hning 
the  eyelids,  and  investing  the  anterior  third  of  the  eyeball,  which, 
in  general,  will  easily  be  distinguished  from  the  diseases  which 
originate  in  or  within  the  proper  tunics  of  the  eye. 

Mr.  Ijawrence  mentioned  in  his  Lectures,t  that  he  had  seen  a 
young  boy,  who  had  an  apparently  simple,  fleshy,  and  vascular 
growth  proceeding  from  the  iris.  It  had  caused  ulceration  of  the 
cornea,  and  thus  protruded  externally.  As  the  patient  hved  in  the 
country,  Mr.  L.  did  not  witness  the  termination  of  the  case,  but  he 
was  informed  that  the  tumour  after  a  time  subsided,  and  that  the 
eye  shrunk  in  the  socket. 

Maitre-Jan  relates  an  interesting  case  of  a  soldier,  whose  eye 
was  completely  covered  by  a  fleshy  excrescence,  which  he  com- 
pares to  a  mushroom,  and  which  projected  even  from  between  the 
eyelids.  He  destroyed  it  by  the  repeated  application  of  one  part 
of  corrosive  sublimate  with  four  of  dry  crust  of  bread,  after  which 
he  discovered  that  its  root  was  narrow,  forcing  its  way  through  an 
ulcer  of  the  cornea,  and  arising  from  the  iris.  Under  the  continued 
use  of  escharotics,  the  front  of  the  eye  sloughed,  and  the  lens  and 
vitreous  humour  were  evacuated,  after  which  the  pain  ceased,  and 
the  ulcer  cicatrized.t 

♦  Histoire  de  1' Academic  Royale  des  Sciences,  pour  1769,  premiere  partie,  p.  86. 
Paris,  1777. 

+  Lancet;  Vol.  x.  p.  514.     London,  1826. 

t  Traite  des  Maladies  de  I'CEil ;  p.  456.     Troyes,  1711. 


451 


SECTION  V. SCIRRHUS  OP  THE  EYEBALL. 

The  eyeball  is  subject  to  at  least  three  malignant  affections ; 
namely,  scirrlius^  medullary  fungus^  and  melanosis. 

Leaving  out  of  view,  for  the  present,  the  last  of  these  diseases, 
which  is  comparatively  rare,  and  has  only  of  late  attracted  particu- 
lar attention,  I  am  led,  from  what  I  have  seen  of  the  malignant 
diseases  of  the  eye,  to  say,  that  the  first  of  the  three  is  slow  in  its 
piogress,  never  ends  in  any  tumour  of  a  very  large  size,  and,  upon 
extirpation,  so  far  from  presenting  any  thing  like  a  fungus,  or  like 
medullary  substance,  is  found  extremely  firm,  and  of  such  a  fibrous 
or  striated  texture,  as  to  merit  the  name  of  scirrhus.  This  degen- 
eration of  the  eye  I  have  never  met  with  except  in  adults  con- 
siderably advanced  in  life,  and  more  frequently  in  women  than 
in  men. 

In  the  second  of  the  three  diseases  above  enumerated,  the  tu- 
mour, after  bursting  through  the  fore-part  of  the  eye,  advances  with 
great  rapidity,  and  often  reaches  an  enormous  size ;  it  presents  a 
spongoid,  or  fungous  texture,  becomes  attended  at  last  by  frightful 
haemorrhage,  and  is  found  on  dissection,  to  consist  of  a  brownish- 
white  substance,  almost  entirely  destitute  of  fibres,  and  which  may 
be  compared,  in  point  of  consistency  and  general  appearance,  to 
brain.  This  kind  of  tumour  I  have  met  with  both  in  children  and 
in  adults,  but  much  more  frequently  in  the  former. 

Extirpation  of  the  eye  is  sometimes  attended  with  complete  suc- 
cess in  the  first  set  of  cases,  although  even  in  these  there  is  a  dan- 
ger of  scirrhus  afterwards  attacking  the  eyelids  or  the  cellular  sub- 
stance of  the  orbit.  In  the  numerous  cases  of  the  second  kind, 
which  have  come  under  my  observation,  the  operation  of  extirpa- 
tion has  never  been  attended  by  permanent  success ;  a  fatal  re- 
production of  fungous  excrescence  from  the  optic  nerve  has  invari- 
ably followed,  and  generally  within  the  period  of  a  few  months. 

The  patient  with  scirrhus  of  the  eyeball  has  always  a  history 
to  give  us  of  Jong-continued  inflammation  in  the  eye,  originating 
in  many  cases  from  cold,  supervening  in  females  about  the  time  of 
life  when  menstruation  ceases,  attended  by  racking  pain  in  the  eye 
and  head,  and  soon  followed  by  dimness  of  sight,  and  at  length  by 
total  blindness.  To  these  symptoms  we  find  that  there  has  suc- 
ceeded a  deformed  and  indurated  state  of  the  eye,  the  cornea  having 
become  opaque,  misshapen,  and  shrunk,  the  sclerotica  of  a  dirty 
yellow  colour,  and  irregularly  prominent,  the  external  blood  vessels 
varicose,  and  the  conjunctiva  sometimes  thickened,  or  even  tuber- 
culated.  The  eye  is  affected  with  sensations  of  itchiness,  burning 
heat,  and  lancinating  pain,  is  overflowed  with  tears  on  the  least 
exposure,  and  is  unable  to  bear  the  slightest  touch.  Severe  hemi- 
crania,  aggravated  during  the  night,  totally  prevents  sleep,  deprives 
the  patient  of  all  desire  for  food,  and  renders  him  unfit  for  any 
continued  employment  of  body  or  mind.    One  of  the  most  remarls- 


452 

able  characteristics  of  this  disease  is  the  length  of  time  during 
which  it  may  continue  without  affecting  the  neighbouring  parts, 
or  advancing  to  ulceration.  At  last,  however,  the  eyelids  and  cel- 
lular membrane  of  the  orbit  are  involved  in  the  carcinomatous  in- 
flammation, the  lids  become  swoln,  red,  and  indurated,  the  eyeball 
is  no  longer  capable  of  motion,  the  lymphatic  glands  of  the  face 
and  neck  become  enlarged  and  painful,  the  conjunctiva  begins  to 
ulcerate,  and  discharges  a  thin  acrid  matter,  the  ulcer  spreads  ,and 
grows  deep,  one  part  after  another  is  destroyed  as  in  cancer  of  the 
eyelid,*  till  the  patient  is  gradually  worn  out  by  fever,  pain,  anxiety, 
and  inanition. 

If  the  eye  is  extirpated  before  the  disease  is  allowed  to  proceed 
to  such  a  length,  the  sclerotica,  especially  near  the  optic  nerve,  is 
found  greatly  thickened,  hard,  almost  cartilaginous,  and,  on  being 
divided  with  the  knife,  presents  the  whitish  bands,  which  are 
deemed  diagnostic  of  scirrhus  ;  the  muscles  of  the  eye  are  similarly 
affected  ;  the  eyeball  itself  is  misshapen,  in  some  cases  shrunk,  in 
others  enlarged ;  its  natural  contents  are  absorbed,  or  if  any  por- 
tion of  them  remain,  they  are  with  difficulty  recognised  ;  while  a 
whitish  or  yellowish  substance,  of  less  firm  consistence  than  the 
sclerotica,  but  like  it  divided  by  membranous  septa,  occupies  the 
place  of  the  vitreous  humour. 

Prognosis  and  Treatment.  Neither  any  internal  medicine,  nor 
external  application  appears  to  have  the  slightest  power  to  arrest 
the  progress  of  this  disease.  Its  nature  is  intractable ;  but  from 
the  slowness  of  its  course,  many  years  may  elapse  before  it  proves 
fatal. 

In  the  early  stage,  that  is  to  say,  so  long  as  the  disease  appears 
to  be  confined  to  the  globe  of  the  eye,  and  this  remains  movable 
in  the  orbit,  extirpation  ought  to  be  had  recourse  to,  and  may  be 
urged  as  a  means  highly  likely  to  be  successful.  If  the  conjunc- 
tiva, eyelids,  or  orbital  cellular  membrane  be  in  any  degree  affected, 
removal  of  the  parts  cannot  be  so  confidently  recommended,  on 
account  of  the  liability  of  the  disease  to  return.  Still,  the  opera- 
tion ought  to  be  adopted,  unless  we  have  reason,  from  the  com- 
pletely fixed  state  of  the  eyeball,  strongly  to  suspect  that  its  mus- 
cles, the  whole  cellular  membrane  of  the  orbit,  and  perhaps  even 
the  periosteum,  are  involved  in  the  scirrhous  degeneration. 

Should  the  patient  refuse  to  submit  to  extirpation  of  the  eye,  or 
should  it  appear  to  the  surgeon,  either  from  the  state  of  the  gene- 
ral health,  or  the  advanced  stage  of  the  local  affection,  that  it  would 
be  improper  to  propose  an  operation,  palliatives  must  be  used  to 
mitigate  the  pain,  and  lessen  the  constitutional  disturbance.  Much 
may  be  done  in  this  way  by  careful  attention  to  the  state  of  the 
bowels,  the  observance  of  a  mild  and  nourishing  diet,  and  the 
avoidance  of  whatever  over-fatigues  the  body,  or  irritates  the  mind. 

*  See  page  121,  &c. 


453 

Narcotics  are  to  be  had  recourse  to,  first  of  all  externally,  as  in  fo- 
mentations and  the  like  ;  and  should  such  applications  fail,  opium 
may  be  administered  in  clyster,  or  by  the  mouth.  In  advanced 
cases  of  ulcerated  cancer  of  the  eye,  large  doses  of  the  preparations 
of  opium  are  absolutely  necessary,  to  relieve  the  sufferings  of  the 
patient. 


SECTION  VI,—- SPONGOID    OR  MEDULLARY    TUMOUR    OF    THE 

EYEBALL. 

The  disease  described  by  Professor  Burns,  under  the  appellation 
of  spotigoid  inflammation*  afterwards  by  Mr.  Hey,  under  that 
of  fungus  hcematodes,  t  and  which  has  been  known  also  by  the 
names  of  medullary  sarcoma  and  soft  cancer,  X  not  unfre- 
quently  attacks  the  eyeball.  A  case  of  this  kind,  in  which  the 
«ye  was  extirpated  by  Mr,  Hunter,  was  described  as  early  as  1767.§ 
Mr.  Hey  also  expressed  his  opinion,  that,  if  he  did  not  mistake, 
this  disease  not  unfrequently  affected  the  globe  of  the  eye,  causing 
an  enlargement  of  it,  with  destruction  of  its  internal  organization ; 
and  that  if  the  eye  were  not  extirpated,  the  sclerotica  burst,  a 
bloody  sanious  matter  was  discharged,  and  th-e  patient  sunk  under 
the  complaint.il  Mr.  Wardrop,  however,  was  the  first  to  prove, 
by  numerous  cases  and  dissections,  that  in  this  opinion  Mr.  Hey 
was  perfectly  correct.*!! 

Sym^ptoms.  This  disease  presents  three  distinct  stages.  In 
the  first,  or  incipient  stage,  the  exterior  form  of  the  eye  is  un- 
changed, and  the  disease  is  perceived  through  the  cornea  and 
pupil.  In  the  second  stage,  the  form  of  the  eye  is  altered,  the 
organ  is  enlarged,  and  its  tunics  are  ready  to  give  way.  In  the 
third,  or  fungous  stage,  the  eye  has  burst,  and  the  tumour  pro- 
trudes. 

\st  Stage.  The  pupil  is  observed  to  be  dilated  and  immovable, 
and  behind  it,  deeply  seated  in  that  part  of  the  eye  naturally  oc- 
cupied by  the  vitreous  humour,  a  yellowish-coloured  appearance 
is  observed,  especially  when  the  eye  is  looked  at  from  one  side, 
■or  the  patient  turns  it  in  certain  directions.  The  light,  especially 
when  not  strong,  is  peculiarly  reflected  from  the  bottom,  or  from 
one  side  of  the  eye,  where  the  retina  is,  or  ought  to  be,  so  that 
there  is  some  resemblance  between  the  eye  in  this  state,  and  that 
■of  a  cat  or  a  sheep,  reflecting  the  light  from  the  tapetum  of  their 
choroid.     By  and  by,  it  is  quite  evident  that  this  appearance,  now 

*  Dissertations  on  Inflammation.     Vol.  ii.  p.  302.     Glasgow,  1800. 

t  Practical  Observations  in  Surgery,  p.  233.     London,   ]803. 

t  Abernethy's  Surgical  Observations,  containing  a  Classification  of  Tumours,  &c. 
p.  51.     London,  1804. 

§  Case  of  a  Diseased  Eye;  by  Mr.  Hayes.  Read  August  26th,  1765.  Medical 
Observations  and  Inquiries.     Vol.  iii.  p.  120.     London,  1767. 

Jl  Op.  cit.  p.  283. 

IT  Observations  on  Fungus  Haematodes,  p.  6.     Edinburgh,  1809. 


454 

become  bright  like  the  reflection  from  the  surface  of  a  brass  plate, 
and  so  remarkable  as  to  attract  the  notice  of  the  most  casual  ob- 
server, arises  from  the  presence  of  a  solid  body  at  the  bottom  of  the 
eye.  Slowly,  in  the  course  of  months,  or  it  may  be  of  years,  this 
body  is  observed  to  be  advancing  towards  the  pupil.  Its  surface 
is  seen  to  be  more  or  less  irregular,  and  partially  covered  with  red 
vessels,  which  are  supposed  to  be  the  ramifications  of  the  central 
artery  of  the  retina.  As  it  advances,  this  body  presses  the  vitreous 
humour  and  crystaUine  lens  before  it ;  the  latter  becomes  opaque ; 
both  are  absorbed  ;  and  the  tumour  touches  the  iris.  At  this  point 
of  its  progress,  it  has  sometimes  been  mistaken  for  cataract,  and 
attempts  have  even  been  made  to  couch  it.  Still  advancing,  it 
presses  the  iris  into  contact  with  the  cornea.  The  iris  loses  its 
natural  colour,  and  becomes  of  a  greyish  or  yellowish  brown. 

This  spongoid,  or  medullary  tumour,  when  once  it  begins  to 
shoot  forwards,  generally  proceeds  with  rapidity.  I  have  known  it 
lie  dormant,  at  the  bottom  of  the  eye,  for  nearly  three  years  ;  but 
in  a  few  weeks  after  commencing  to  advance,  it  not  only  occupied 
the  whole  cavity  of  the  eye,  but  dilated  it  to  more  than  thrice  its 
natural  size,  the  first  stage  hurrying  thus  into  the  second. 

This  first  stage  of  the  disease  is,  in  general,  unattended  by  pain 
or  external  inflammation  ;  but,  in  some  cases,  inflammation  of  the 
eye  is  the  very  first  symptom  which  attracts  attention. 

2d  Stage.  By  the  end  of  the  first  stage,  the  sclerotica,  around 
the  cornea,  has  probably  assumed  a  leaden  colour,  and  the  eye, 
fixed  in  the  orbit,  appears  larger  than  natural.  These  symptoms 
soon  become  more  decided,  and  are  attended,  from  time  to  time, 
by  smart  attacks  of  pain  and  external  inflammation.  The  form 
of  the  eye  is  changed.  It  grows  knobbed  at  one,  or  several  places, 
the  sclerotica  becoming  extenuated,  and  the  tumour  pressing  out- 
wards. In  some  cases,  the  eye  turns  very  much  inwards  or  out- 
wards, so  that  the  cornea  is  scarcely  to  be  seen,  while  the  tumour 
pushes  its  way  through  the  sclerotica,  either  at  the  temporal  or 
nasal  edge  of  the  cornea,  according  as  the  eye  is  turned  inwards  or 
outwards.  In  other  cases,  we  see  the  tumour  advancing  into  con- 
tact with  the  cornea,  between  the  lamellae  of  which,  matter  is  at 
last  eff"used,  ulceration  follows,  and  the  cornea  bursts. 

3f/  Stage.  The  tumour,  protruding  through  the  ruptured  cor- 
nea or  sclerotica,  (in  the  latter  case  covered  for  a  while  by  the  con- 
junctiva, which  it  pushes  before  it),  grows  with  great  rapidity,  and 
assumes  the  appearance  of  a  dark-red  fungus,  irregular  on  its  sur- 
face, soft,  readily  torn,  and  bleeding  profusely  on  the  slightest  irri- 
tation. Portions  of  it  die  and  slough  off"  from  time  to  time,  but  the 
general  bulk  of  the  fungus  is  not  at  all  reduced.  On  the  contrary, 
it  increases  so  as  to  distend  the  eyelids  to  an  eno:  mous  degree, 
and  even  to  dilate  or  destroy  the  orbit,  while  the  portion  which 
projects  from  that  cavity,  and  overhangs  the  cheek,  sometimes  ex- 
ceeds the  size  of  a  man's  £st. 


455 

The  lymphatic  glands  of  the  cheek  and  neck  become  enlarged, 
sometimes  to  a  very  great  degree. 

The  patient  becomes  affected  with  great  constitutional  irritation, 
restlessness,  thirst,  want  of  sleep,  and  disturbance  of  all  the  func- 
tions of  the  body  ;  and  at  length  expires,  exhausted  by  loss  of  blood, 
and  worn  out  by  hectic  fever. 

Appearances  on  dissection.  I  have  now  before  me  an  eye,  ex- 
tirpated by  the  late  Dr.  Monteath,  during  the  first  stage  of  this  dis- 
ease. Immediately  after  the  operation,  I  divided  the  cornea  and 
sclerotica  by  a  crucial  incision,  and  laid  back  the  four  flaps.  The 
iris  and  choroid  were  entire.  I  divided  them  in  Hke  manner,  laid 
them  back,  and  along  with  the  choroid,  I  found  that  I  reflected  also 
the  retina,  which,  though  broken,  and  here  and  there  deficient,  is 
still  sufficiently  entire  to  give  a  white  coating  to  the  whole  internal 
surface  of  the  choroid,  and  has  evidently  nothing  to  do  in  this  in- 
stance with  the  medullary  tumour,  which  occupies  the  whole  space 
of  the  vitreous  humour  and  crystaUine  lens,  and  springs  from  the 
optic  nerve,  as  from  a  root.  The  tumour,  enveloped  in  a  mem- 
brane similar  to  the  hyaloid,  was  of  the  consistence  of  brain,  and  of 
a  yellowish-white  colour.  The  optic  nerve  exterior  to  the  scleroti- 
ca, did  not  appear  diseased. 

The  subject  from  w"hora  this  eye  was  removed,  was  a  child  of 
about  three  years  of  age.  In  a  few  months  after  the  operation,  the 
orbit  was  filled  with  a  new  tumour,  and  the  child  soon  after  died. 
I  carefully  examined  the  parts,  and  have  them  now  before  me. 
The  orbit  was  occupied  by  a  diseased  mass,  sprouting  from  the 
stump  of  the  optic  nerve,  and  similar  in  texture  to  that  which  had 
formerly  existed  within  the  eye.  I  opened  the  cranium,  and  found 
the  optic  nerves,  from  their  origin  in  the  brain  to  their  union,  ap- 
parently healthy  ;  but  from  their  union  to  the  optic  foramen,  the 
nerve  of  the  diseased  side  was  as  thick  as  the  middle  finger.  By 
passing  through  the  optic  foramen,  it  was  strictured  as  if  it  had  been 
surrounded  by  a  ligature,  but  instantly  on  entering  the  orbit,  it  again 
expanded,  so  as  to  fill  the  space  between  the  recti.  The  tumour, 
covered  by  these  muscles,  filled  the  orbit  so  completely,  that  it  still 
retains  the  pyramidal  form  of  that  cavity. 

The  appearances  on  dissection  in  this  disease,  are  very  far  from 
being  uniform.  They  may  all,  however,  be  referred  to  the  eflfects 
of  a  medullary  growth  from  the  optic  nerve. 

Although  the  retina  was  tolerably  entire  in  the  case  which  I 
have  just  related,  in  general  it  is  so  completely  changed,  that  no 
part  of  it  can  be  detected.  In  the  case  before  me,  the  tumour  had 
pressed  forwards  from  the  end  of  the  optic  nerve,  within  the  retina, 
in  such  a  manner  as  to  produce  the  complete  displacement  and  ab- 
sorption of  the  vitreous  humour  and  crystalUne  lens  ;  but  in  some 
cases,  the  tumour  has  been  known  to  push  itself  between  the  scle- 
rotica and  choroid,  while  in  other  instances,  the  fungus  has  arisen 
from  the  optic  nerve,  before  its  entrance  into  the  eye,  and  proved 


456 

destnictive  to  this  organ,  by  pressure  exercised  on  it  from  without. 
It  may  even  happen  tiiat  there  shall  be  several  fungous  growths, 
arising  in  succession,  but  latterly  going  on  together,  one  perhaps 
behind  the  sclerotica,  another  between  the  sclerotica  and  choroid,- 
and  a  third  within  the  retina. 

The  sclerotica  appears  to  suffer  less  from  this  disease  than  any 
other  part  of  the  eye. 

The  choroid  is  sometimes  pushed  to  one  side  by  the  tumour,  and 
on  dissection,  appears  Uke  an  irregularly  shaped  bag,  containing- 
vitreous  humour.  In  some  cases,  shreds  merely  of  the  choroid  can 
be  discovered,  dispersed  through  the  morbid  growth.  In  other 
cases,  portions  of  the  choroid  are  increased  to  five  or  six  times  the 
natural  thickness.  Occasionally,  no  trace  of  this  membrane 
appears. 

The  humours  are  alDsorbed  in  proportion  to  the  pressure  of  the 
tumour,  and  in  cases  where  it  has  burst  through  the  sclerotica  or 
cornea,  they  are  generally  altogether  destroyed. 

I  believe  that,  on  minute  examination,  it  will  rarely  be  found  that 
the  optic  nerve  exterior  to  the  eye,  presents  a  healthy  structure.  It 
will,  in  general,  be  found  thicker  than  natural,  softer,  of  a  yellowish 
colour,  and  presenting,  instead  of  a  bundle  of  nervous  filaments,  as 
it  ought  to  do,  a  uniform  pulpy  substance.  In  other  instances,  the 
nerve  is  contracted,  lying  loose  in  its  neurilema,  firmer  than  natural, 
and  of  a  reddish  colour.  In  some  cases,  the  nerve  is  found  to  be 
split  into  several  pieces,  tiie  morbid  growth  filling  up  the  interven- 
ing spaces,  surrounding  the  several  portions  of  the  nerve,  and  form- 
ing one  connected  mass  with  the  contents  of  the  eyeball. 

The  diseased  state  of  the  nerve  will  in  general  be  found  to  extend 
to  that  portion  of  it  which  is  contained  within  the  cranium,  and  in 
many  cases,  the  brain  itself  is  affected,  being  changed  into  a  soft 
pulpy  mass,  and  presenting  cavities,  either  in  the  substance  of  the 
part  which  has  suffered  the  spongoid  degeneration,  or  around  it, 
filled  with  blood. 

The  tumour  varies  in  appearance  in  different  cases,  but  has  al- 
ways more  or  less  resemblance  to  the  medullary  substance  of  the 
brain,  being  in  general  opaque,  v.'hitish,  homogeneous,  and  pulpy. 
Like  brain,  it  becomes  soft  when  exposed  to  the  aii',  mixes  readily 
with  cold  water,  and  dissolves  in  it :  while  in  alcohol  or  acids,  it 
becomes  firm,  or  even  hard.  When  the  softer  parts  are  washed 
away  in  water,  or  when  the  mass  is  forcibly  compressed,  the  more 
solid  parts  remain,  and  are  found  to  consist  of  a  filamentous  sub- 
stance, resembling  cellular  membrane.  The  consistence  of  the  tu- 
mour varies,  to  a  certain  extent,  in  different  cases,  and  in  different 
parts  of  the  same  tumour,  being  in  some  as  fluid  as  cream,  in  others 
firmer  than  the  most  solid  parts  of  a  fresh  brain.  In  some  rare  in- 
stances, gritty  particles,  probably  bony,  have  been  found  interspersed 
through  the  morbid  growth.  The  colour  of  the  tumour,  although 
commonly  that  of  the  medullary  substance  of  the  brain,  or  a  very 


457 

little  darker,  is  sometimes  redder,  or  even  of  a  dark  brown  colour, 
while,  in  the  advanced  stage,  it  often  presents  portions  which  nearly 
resemble  clots  of  blood. 

When  the  absorbent  gland  lying  over  the  parotid,  or  any  of  the 
absorbent  glands  of  the  neck,  are  enlarged  in  this  disease,  they  are 
found  to  be  converted  into  a  substance  resembling,  in  every  respect, 
that  which  composed  the  tumour  of  the  eyeball  and  brain.  In 
some  cases,  the  glands  ulcerate  before  death,  and  form  a  very  un- 
healthy sloughy  ulcer,  but  most  frequently  the  patient  dies  before 
the  skin  covering  them  is  destroyed.  Mr.  Wardrop  mentions,  that 
after  the  skin  covering  such  contaminated  glands  had  given  way, 
he  never  observed  any  fungus  to  arise  from  them. 

On  examining  the  bodies  of  those  who  die  of  spongoid  tumour  of 
the  eye,  the  same  disease  is  sometimes  discovered  in  the  viscera 
of  the  abdomen  or  thorax ;  especially  in  the  liver,  kidneys,  uterus, 
or  lungs. 

Subjects.  This  disease  is  much  more  frequent  in  children  than 
in  adults.  Out  of  twenty -four  cases  which  had  come  to  Mr.  Ward- 
rop's  knowledge,  twenty  of  them  occurred  in  subjects  under  twelve 
years  of  age.  The  greatest  number  of  cases  has  been  observed  in 
children  from  two  to  four  years  old.  Sometimes  the  disease  has 
been  met  with  within  a  few  months  after  birth.  Instances  have 
happened,  on  the  other  hand,  in  which  it  has  attacked  adults,  or 
even  persons  far  advanced  in  life. 

The  children  who  fall  victims  to  this  disease,  are  generally  of  a 
well-marked  strumous  constitution. 

Exciting  Causes.  In  many  of  the  cases  on  record,  a  blow  on 
the  eye  is  mentioned  as  having  preceded,  and  apparently  excited 
this  disease.  It  may  be  doubted,  however,  whether  the  blindness 
of  the  affected  eye  does  not  render  children  more  liable  to  meet  with 
blows  on  that  side,  after  which,  the  eye  being  examined,  may  be 
found  to  present  symptoms  which  had  previously  existed,  but  with- 
out attracting  attention. 

Diagnosis.  Mr.  Lawrence  stated,  in  his  Lectures,  that  many 
cases  occur  of  changes  of  structure  producing  all  the  visible  appear- 
ances of  fungus  haematodes  of  the  eye,  but  which  do  not  turn  out 
to  be  malignant.  "  We  have  seen  children  at  this  Infirmary,"" 
said  he,  "  with  the  appearances  of  fungus  haematodes  in  the  first 
stage,  namely,  the  altered  colour  of  the  pupil,  the  metallic  reflection 
in  the  bottom  of  the  eye,  and  so  on.  The  uniformly  unfavourable 
result  of  extirpation  has  deterred  us  from  proposing  the  opera- 
tion. Yet  in  some  instances,  very  contrary  to  our  expectation,  the 
case  has  remained  for  some  time  in  that  state,  and  afterwards,  instead 
of  destroying,  the  globe  has  shrunk,  and  become  atrophic."t  Mr. 
Travers,  also,  has  lately  published  some  important  observations  on 
the  difficulties  attending  the  diagnosis  of  this  disease.     He  is  of  opin- 

*  London  Ophthalmic  Infirmary,  Moorfields. 

t  Lectures  in  the  Lancet,  Vol.  x.  p.  518.     London,  1826. 

68 


458 

ion  that  the  tapetum-lil-e  appearance  at  the  bottom  of  the  eye,  in 
the  early  stage,  cannot  be  rehed  on  as  diagnostic.  He  mentions  that 
he  had  seen  several  cases,  in  which  this  appearance  was  stationary 
for  a  time,  after  which  the  eyeball  dwindled,  so  that  they  might 
fairly  be  presumed  not  to  have  been  instances  of  mahgnant  disease. 
It  so  happened,  however,  that  long-continued  alterative  courses  of 
mercury  or  protracted  salivations  had  been  used  in  these  cases,  so 
that  the  fact  of  their  disappearance  was  consequently  open  to  anoth- 
er explanation,  namely,  that  they  were  examples  of  mahgnant  dis- 
ease, which  had  been  arrested  by  this  treatment.  That  the  appear- 
rance  in  these  cases  was  very  analogous  to  that  of  medullary  tumour, 
we  may  readily  admit  from  the  fact,  that  in  one  of  them,  the  extir- 
pation of  the  eye  w^as  over-ruled  only  b}'  one  dissentient  voice,  at  a 
consultation,  including  some  eminent  members  of  the  profession  : 
and  although  Mr.  Travers  had  on  two  several  occasions  sat  down  to 
perform  the  operation.  The  patient,  a  lady,  had  recovered  with  the 
loss  of  sight,  several  years  before  Mr.  T.  published  this  statement 
of  her  case,  and  still  continued  in  perfect  health. 

It  accords  exactly  with  my  own  experience,  that  the  adhesive 
inflammation  of  the  choroid,  terminating  in  a  deposite  of  lymph, 
w^hich  undergoes  vascular  organization  between  that  membrane 
and  the  retina,  presents  an  appearance  exactly  resembling  incipient 
medullary  tumour.  Mr.  Travers  states  that  in  a  young  lady's  eye, 
the  fawn-coloured  resplendent  surface,  with  red  vessels  branching 
over  it,  was  so  strongly  marked,  that  he  should  certainly  have  con- 
sidered it  to  be  the  nascent  malignant  disease,  but  for  the  circum- 
stance of  its  having  followed  a  wound  with  a  pair  of  fine  scissors, 
a  fortnight  before.  The  instrument  had  passed  obliquely  between 
the  margin  of  the  iris  and  the  ciliary  body.  Deep-seated  inflam- 
mation ensued,  and  bUndness,  after  three  days,  became  complete. 
The  lens  remained  transparent  for  months,  so  as  to  permit  the  ap- 
pearances described  to  be  observed.  At  length,  a  cataract,  with 
constricted  pupil,  ensued  upon  the  chronic  inflammation  of  the  iris ; 
and  the  e3-eball,  which  had  never  enlarged,  gradually  shrunk. 

Chronic  choroiditis  also  is  occasionally  productive  of  appear- 
ances, which  are  very  similar  to  those  of  medullary  tumour. 
Lymph  appears  to  be  effused,  to  become  organized,  and  even  to 
advance  towards  the  cornea,  producing  an  absorption  of  the  vitreous 
humour.  I  have  known  cases  of  this  sort,  which  continued  for 
many  months,  without  either  manifesting  hydrophthalmic  enlarge- 
ment, or  shrinking  by  interstitial  absorption  of  the  contents  of  the 
eyeball,  two  sure  indications,  as  Mr.  Travers  remarks,  that  the 
disease  is  not  mahgnant. 

Such  are  some  of  the  difficulties  attending  the  diagnosis  in  the 
early  stage  of  medullary  tumour.  In  the  fungous  stage,  it  is  apt 
to  be  confounded  with  exophthalmia,  arising  from  the  pressure  of 
encysted  or  other  tumours  in  the  orbit,  or  from  severe  inflammation 
of  the  orbital  cellular  membrane.     A  deep  transverse  section,  from 


459 

the  outer  to  the  inner  canthus  of  the  enlarged  eye,  so  as  completely 
to  evacuate  its  contents,  is  an  efficient  remedy  in  simple  exophthal- 
mia,  which  is  always  attended  with  great  disfigurement  from  pro- 
trusion, excessive  vascularity  of  the  conjunctiva,  and  agonizing 
sympathetic  heniicrania  on  the  same  side  with  the  diseased  eye. 
In  the  medullary  tumour,  this  proceeding  is  of  no  avail ;  but,  as 
Mr.  Travers  advises,  if  any  doubt  of  the  nature  of  the  case  exist, 
it  should  be  practised.  In  the  malignant  disease,  the  globe  remains 
firm,  the  section  being  followed  only  by  a  small  discharge  of  blood ; 
but  if  a  considerable  discharge  of  discoloured  fluid  or  matter  takes 
place,  and  the  globe  collapses,  the  disease  is  not  mahgnant,  and 
the  cure  is  complete.* 

Treatment.  Medullary  tumour,  like  cancer,  has  hitherto  resisted 
the  power  of  all  external  or  internal  medicines. 

Extirpation  of  the  eye  has  frequently  been  performed  on  account 
of  this  disease,  but  it  may  fairly  be  doubted  whether  it  has  in  any 
one  instance  eflfected  a  radical  cure.  In  many  cases,  the  disease 
has  certainly  been  known  to  return  after  extirpation  of  the  eye, 
the  optic  nerve  having  probably  been  diseased  previously  to  the 
operation,  or  at  all  events,  giving  rise  to  a  new  medullary  growth, 
sufficient  to  fill  the  orbit  in  the  course  of  a  few  months,  so  that 
although  the  removal  of  the  eye  may  have  saved  the  patient  from 
the  suffering  which  always  attends  the  rupture  and  destruction  of 
that  organ,  yet  it  probably  hastens  rather  than  retards  the  fatal 
termination  of  the  disease.  The  extirpation  of  the  eye  has  always 
failed,  when  the  disease  was  so  far  advanced  that  the  posterior 
chamber  was  filled  by  the  fungous  mass ;  whether  it  might  be 
more  successful,  were  it  performed  when  the  disease  first  appears 
at  the  bottom  of  the  eye,  it  is  impossible  to  say.  At  that  early 
period,  the  friends  of  the  patients  could  scarcely  be  expected  to  bring 
themselves  to  consent  to  extirpation  of  the  eye,  nor,  after  the  state- 
ments of  Mr.  Lawrence  and  Mr.  Travers,  regarding  the  uncer- 
tainty of  the  diagnosis,  could  the  surgeon  fairly  insist  on  this  mea- 
sure, as  being  absolutely  indicated. 

During  the  inflammatory  attacks  which  attend  the  progress  of 
medullary  tumour  within  the  eye,  advantage  will  be  derived  from 
the  application  of  leeches  to  the  temple,  a  spare  diet,  laxatives,  and 
evaporating  lotions.  In  the  advanced  stages  of  the  disease,  opiates 
will  be  required  internally;  and  their  ex'ternal  application  also 
gives  relief 


SECTION  VII MELANOSIS  OF  THE  EYEBALL. 

To  this  malignant  tumour  or  disposition,  Laennec  gave  the 
name  of  melanosis^  on  account  of  its  black  colour.*     Equivocal 

*  Observations  on  the  Local  Diseases  termed  Malignant,  by  Benjamin  Travers ; 
in  the  Medico-Chirurgical  Transactions,  Vol.  xv.  p.  235.    London,  1829. 
M«wtf,  black. 


460 

traces  of  it  are  to  be  found  in  the  works  of  Morgagni,  Bonetus,  and 
Haller  ;  but  the  continental  pathologists  of  our  own  times  have 
been  the  first  to  treat  of  this  affection  as  distinct  and  peculiar.  In 
the  beginning  of  the  present  century,  Bayle  and  Laennec  first  pub- 
lished upon  the  subject ;  but  it  would  appear  from  a  controversy 
which  arose  on  that  occasion,  that  M.  Dupuytren  had  been  ac- 
quainted with  this  disease  several  years  before,  and  had  annually 
mentioned  it  in  his  lectures.*  Since  this  period,  melanosis  has  at- 
tracted the  attention  of  numerous  pathologists,  both  on  the  conti- 
nent and  in  this  country  ;  of  whom  we  may  mention  particularly 
M.  Breschet,  who  has  inserted  a  paper  on  the  subject  in  the  first 
volume  of  Majendie's  Journal,  and  Mr.  Fawdington,  who  has 
given  to  the  pubhc  an  interesting  case  of  this  disease,  with  gene- 
ral observations  on  its  pathology,  and  eight  admirable  lithographic 
plates,  illustrative  of  its  appearances  in  various  organs  of  the 
body. 

The  most  striking  physical  character  of  melanosis,  in  whatev- 
er region  of  the  body,  or  under  w^hatever  form  it  occurs,  is  its 
black  or  dark  colour,  varying  from  the  hue  of  Indian  ink  to  a 
brownish  yellow,  but  in  general  approaching  near  to  the  former. 
In  consistence,  the  product  of  melanosis  bears  a  considerable  re- 
semblance to  that  which  the  contents  of  a  decaying  lycoperdon  or 
common  puff-ball  would  present,  if  rendered  cohesive  by  the  addi- 
tion of  a  small  quantity  of  liquid.  Melanosis  displaces  or  destroys 
the  different  textures  of  the  body  in  a  variety  of  ways.  It  is  most 
frequently  met  with  in  tubercles,  or  even  in  considerable  masses  : 
is  sometimes  encysted,  and  connected  to  the  neighbouring  parts 
by  pedicles  ;  sometimes  diffused  through  the  parenchyma  of  the 
viscera ;  in  other  cases,  deposited  upon  their  surface,  or  under 
their  investing  membrane.  It  appears  that  no  tissue  is  free  from 
the  invasion  of  this  disease,  although  it  attacks  some  parts  more 
readily  than  others.  In  its  progress,  however,  it  involves  indiscrim- 
inately the  adjacent  textures,  supplanting  and  destroying  all  that 
oppose  a  barrier  to  its  ravages.  Even  the  bones  are  not  exempt 
from  Its  influence.  Some  of  the  lower  animals,  and  especially  the 
horse,  are  subject  to  this  disease. 

M.  Breschet  has  been  at  some  pains  to  ascertain  whether  the  sub- 
stance of  melanosis  is  truly  organized.  With  this  view,  he  threw 
into  the  arteries  and  veins  of  the  contiguous  parts,  some  of  the 
finest  and  most  diffusible  injections,  without  discovering  any  con- 
tinuity of  vessel  between  the  cyst  and  the  substance  it  contained, 
or  any  organization  in  the  latter. 

The  composition  of  the  tumours  in  melanosis  has  been  ascer- 
tained, by  chemical  analysis,  to  approach  very  nearly  to  that  of  the 
coagulum  of  the  blood.  In  fact,  with  the  exception  of  the  black, 
colouring  matter,  all  the  other  elements  are  the  same  with  those  of 

•  Journal  de  Medecine  de  Corvisart,  Tomes  ix  et  i. 


461 

the  coagulum.  Thenard  and  Barruel  recognized  a  large  quantity 
of  carbon  in  melanosis,  and  to  tliis  some  have  attributed  the  black 
colour  of  this  disease. 

From  these  results  of  the  anatomical  and  chemical  examination 
of  melanosis,  it  has  been,  perhaps  hastily,  inferred,  that  the  sub- 
stance which  collects  in  this  disease  is  the  product  simply  of  a  se- 
creting action  of  the  original  exhalent  system  ;  or,  in  other  words, 
an  exudation  of  one  of  the  constituents  of  the  blood,  slightly  modi- 
fied in  its  transmission  through  the  capillaries.  Mr.  Fawdington 
justly  remarks  that  this  opinion  is  hardly  tenable,  when  we  consid- 
er how  entirely  absent  the  common  signs  of  vascular  congestion  are 
in  this  disease,  and  how  unlike  its  character  is  to  that  which 
would  result  from  a  simple  secretion  or  effusion.  Although  ap- 
parently destitute  of  vessels,  it  is  probable  that  melanosis  is  not 
beyond  the  pale  of  a  vital  influence,  but  possesses,  like  many 
other  tumours,  an  inherent  power  of  growth,  controlled  by  laws  as 
yet  unknown,  but  different  from  those  which  regulate  the  increase 
of  such  diseases  as  present  an  unequivocal  vascularity. 

Melanosis  is  undoubtedly  of  a  fungous  nature,  and  being  not  un- 
frequently  found  in  conjunction  with  other  kinds  of  fungous  disease, 
especially  the  medullary,  it  has  been  regarded  by  Mr.  Wardrop* 
and  others,  merely  as  a  variety  of  fungus  haematodes.  This  view 
has  been  countenanced  by  the  fact,  that  tumours  have  been  met 
with,  possessing  almost  every  possible  degree  of  intermediate  feature, 
as  so  to  render  it  difficult  to  determine  whether  the  character  of 
melanosis  or  that  of  medullary  fungus  prevailed.  If,  however, 
we  take  the  extreme  state  of  each  disease,  we  discover,  (as  Mr. 
Fawdington  observes,)  differences  of  a  very  marked  and  striking 
character. 

In  the  anatomical  structure  of  melanosis,  the  paucity  or  entire 
want  of  vessels,  constitutes  a  distinguishing  peculiarity  ;  while  me- 
dullary tumour,  which  invades  the  system  as  extensively,  appears 
under  similar  forms,  attacks  the  same  textures,  and  eventually  pro- 
duces a  like  influence  on  the  general  economy,  is  as  remarkable  for 
a  contrary  state,  namely,  a  luxuriant  vascularit}^,  Laennec  re- 
marked that  fungus  haematodes  is  in  general  supplied  by  a  great 
many  blood  vessels,  the  trunks  of  which  ramify  on  the  exterior  of 
the  tumours,  or  between  their  lobes  only,  while  the  minuter  branch- 
es penetrate  into  the  substance  of  the  morbid  growth  ;  and  that  the 
coats  of  these  vessels  being  very  fine,  they  are  readily  ruptured, 
thus  giving  rise  to  clots  of  extravasated  blood  in  the  interior  of  the 
tumours,  sometimes  of  considerable  size.  Nothing  of  this  kmd  is 
observable  in  melanosis,  no  extraordinary  development  of  arterial 
branches  leading  to  the  tumours,  none  visibly  ramifying  on  the 
cysts  which  surround  them,  none  in  the  morbid  substance. 

Mr.  Fawdington  has  carefully  compared  the  local  phenomena 

*  Observations  on  diseased  Structures,  prefixed  to  the  second  volume  of  Baillie'S 
Works,  p.  liii.    London,  1825. 


462 

presented  during  life  by  these  two  diseases.  In  fungus  hsematodes, 
if  the  tumour  be  at  all  advanced,  there  is  pain,  constant  or  occa- 
sional, sharp  and  lancinating,  and  often  accompanied  by  signs  of 
low  vascular  excitement.  In  a  farther  stage,  the  suffering  is 
increased  ;  an  ulcerated  breach  having  been  produced  in  the  in- 
teguments, the  fungus  grows  and  sloughs  by  turns  ;  it  discharges 
an  offensive  sanies,  and  considerable  haemorrhages  take  place, 
which  for  a  time  reheve  both  the  vascular  and  nervous  irritation 
attendant  on  the  progress  of  the  disease.  Lastly,  the  absorbent 
glands  in  the  vicinity  participate  in  the  mischief,  and  the  general 
powers  become  exhausted,  from  the  combined  influence  of  pain, 
irritation,  and  discharge.  Now,  in  melanosis,  unless  the  growth  of 
the  tumour  be  circumscribed  by  textures  which  yield  with  difficulty, 
such  as  the  tunics  of  the  eyeball,  or  the  cavity  of  the  orbit,  there  is 
neither  pain,  as  a  necessary  concomitant,  nor  an  excited  state  of 
vessels  in  the  circumjacent  structures.  As  to  the  phenomena  of 
melanosis  in  the  ulcerative  stage,  there  seems  to  be  a  blank  which 
must  be  left  to  future  observers  to  fill  up  ;  but  reasoning  from  its 
low  state  of  organization,  it  may  be  concluded  that  many  of  the 
pathological  changes  which  attend  the  career  of  fungus  haematodes, 
wnll  not  be  found  to  exist  in  melanosis.  The  process  upon  which 
the  softening  of  this  tumour  depends,  is  as  inexplicable  as  the  laws 
of  its  production  and  increase  :  but  that  it  arises  from  a  power  in- 
herent in  the  morbid  structure,  and  distinct  from  the  common  con- 
ditions of  suppurative  inflammation  in  other  structures,  is  to  be  in- 
ferred from  the  absence  of  those  agents  which  support  the  latter  in 
the  situation  where  the  softening  is  first  observed. 

Symptoms  of  Melanosis  of  the  Eyeball.  The  cases  on  record 
are  too  few  to  enable  us  to  say  more  under  this  head,  than  that  the 
patient  complains  in  the  early  stage  of  imperfect  or  destroyed  vision, 
with  a  sense  of  fulness  and  pain  in  and  round  the  eye,  followed  by 
enlargement  of  the  eyeball,  extenuation  of  the  sclerotica,  and  a  pe- 
culiar opaque  appearance  of  the  pupil.  Neither  in  Mr.  Allan 
Burns's  case,  nor  in  Mr.  Fawdington's,  did  the  eye  give  way,  so 
that  we  are  unable  to  state  what  may  be  the  termination  of  this 
disease,  when  the  eye  is  left  to  itself.  Both  patients  died  of  melan- 
osis in  the  viscera,  after  the  affected  eye  was  extirpated. 

Like  fungus  hccmatodes,  melanosis  occasionally  occurs  exterior 
to  the  eyeball,  in  the  cellular  membrane  of  the  orbit.  In  this  case, 
the  tumour  pushes  the  eye  before  it,  and  at  last  the  eye  is  destroyed 
by  inflammation.* 

Cases.  The  following  is  an  abridged  account  of  the  two  cases 
above  referred  to. 

Case  1.  In  Mr.  Wardrop's  work  on  Fungus  Haematodes,  and 
again  in  Mr.  Allan  Burns's  Observations  on  the  Surgical  Anatomy 

*  See  a  cise  of  Melanosis  by  Dr.  Chomel,  quoted  from  the  3cl  volume  of  the  Nou- 
veau  Journal  de  Medecine,  in  the  Dictiongire  des  Sciences  Aledicales,  Tome  xxiii. 
p.  187.     Paris,  1819. 


463 

of  the  Head  and  Neck,  a  well-marked  case  of  melanosis  of  the  eye 
is  related  merely  as  a  variety  of  meduDar}^  tumour. 

The  patient,  Mrs.  Scott,  about  41  years  of  age,  had  always  been 
of  a  delicate  habit  of  body,  and  sallow  complexion.  The  progres- 
sive advancement  of  the  disease  of  the  eye  appears  to  have  occupied 
a  period  of  two  years  and  a  half.  It  first  manifested  itself,  by  the 
patient  being  unable  to  see  distinctly  with  her  left  eye ;  and  on 
looking  at  the  organ,  a  milkiness  was  seen  behind  the  pupil.  This 
opacity,  which  Mr.  Burns  speaks  of  as  seated  in  the  lens,  gradually 
increased  during  four  months,  when  the  patient  became  completely 
blind  of  that  eye.  About  four  months  after  losing  the  sijjht  of  the 
eye,  it  became  very  much  inflamed,  without  any  obvious  cause. 
By  bleeding  with  leeches,  &c.  the  inflammation  abated,  but  the 
redness  and  pam  never  entirely  left  the  eye.  From  what  Mr.  B. 
had  been  able  to  learn,  the  opacity  of  the  lens  could  not  be  so  de- 
cidedly ascertained  after  this  attack,  owing  to  the  turbid  state  of  the 
contents  of  the  anterior  chamber. 

The  further  progress  of  the  case  was  not  traced  till  within  six 
months  of  the  time  when  Mr.  B.  thought  it  necessary  to  remove 
the  contents  of  the  orbit  by  operation.  At  the  beginning  of  that 
period,  a  tumour  began  to  protrude  from  the  lower  side  of  the  scle- 
rotic coat;  just  behind  the  edge  of  the  cornea.  Two  months  after 
this,  Mr.  B.  found  the  cornea  rather  more  prominent  than  usual, 
but  he  could  distinguish  with  accuracy  neither  the  iris  nor  thecrys- 
talhne  lens.  The  appearance  impressed  him  with  the  idea,  that  a 
fungus  was  lodged  behind  the  cornea,  ready  to  protrude  so  soon 
as  the  cornea  gave  way.  The  tumour  at  the  lower  part  of  the 
sclerotica  was  now  about  the  size  of  a  musket-ball,  and  seemed  to 
contain  a  dark-coloured  fluid,  the  cyst  being  formed  by  that  part  of 
the  conjunctiva  which  covers  the  sclerotica,  while  over  the  surface 
of  the  sac  a  number  of  red  vessels  ran  in  every  direction.  The 
pain  was  intense  and  lancinating  ;  sleep  was  interrupted,  and  be- 
sides being  affected  with  hysteria  and  pain  in  the  back,  the  patient 
was  in  some  degree  hectic. 

After  four  months  more,  matters  were  in  a  much  worse  state, 
and  the  patient's  health  completely  broken  ;  she  had  confirmed 
hectic  fever,  and  was  often  attacked  with  paroxysms  of  hysteria ; 
she  was  much  reduced  and  exceedingly  weak,  and  had  not  been 
out  of  bed  for  two  months.  The  cyst,  which  formerly  had  not 
been  larger  than  a  musket-ball,  had  now  attained  the  size  of  a 
pigeon's  egg,  and  formed  a  solid  fungous  mass,  which  could  with 
difficulty  be  raised,  so  as  to  uncover  the  under  eyelid.  The  cornea 
was  flat,  and  was  hid  beneath  the  upper  eyelid.  From  the  body 
of  the  large  fungus,  two  small  fungi  protruded,  and  towards  the 
temporal  extremity  of  the  lower  eyelid,  there  was  a  hard  tumour, 
situated  under  the  integuments,  and  adhering  firmly  to  the  cheek- 
bone. 

The  patient  was  anxious  to  have  the  parts  removed  by  operation, 


464 

which  was  accordingly  done  by  Mr.  Burns,  assisted  by  Mr.  Ward- 
Top.  As  the  tumour  exterior  to  the  eyelids  was  of  considerable 
size,  Mr.  B.  separated  them  by  an  incision  at  their  temporal  angle. 
He  then  grasped  the  tumour,  and  dissected  back  the  lids  from  it» 
As  he  wished  to  take  out  all  the  diseased  parts  in  connexion,  he 
endeavoured  to  detach  them  from  the  lower  margin  of  the  orbit ; 
but,  to  his  surprise  and  regret,  he  found  that  the  bone  on  which 
they  rested  was  softened  and  black  in  colour.  He  therefore  gave 
up  the  attempt,  and  proceeded  to  detach  the  eyeball  from  its  con- 
nexions, with  a  common  scalpel.  While  separating  it  from  the 
roof  of  the  orbit,  he  was  cautious,  lest,  the  bone  being  there  soft^ 
the  point  of  the  knife  might  pass  into  the  brain.  By  the  pressure 
employed  in  pulling  forward  the  morbid  parts,  they  burst,  and  a 
considerable  quantity  of  inky  fluid  was  poured  from  the  opening, 
Mr.  B.  traced  the  optic  nerve  to  its  exit  from  the  skull,  and  there 
divided  it.  Even  there  its  medullary  substance  was  as  black  as 
ink.  He  next  chisseled  away  as  much  as  he  could  of  the  diseased 
edge  of  the  orljit.  but  with  little  hope  that  the  issue  of  the  operation 
would  be  favourable.  The  diseased  state  of  the  optic  nerve,  and 
the  condition  of  the  lx)ne,  hardly  allowed  any  reasonable  expecta- 
tion that  the  patient  would  ultimately  recover.  The  bleeding  from 
the  divided  vessels  was  easily  restrained  b}"  the  pressure  of  a  plug 
of  lint. 

As  soon  as  possible  after  the  operation,  a  section  was  made  of 
the  morbid  parts  which  had  been  removed.  When  dividing  the 
eyebciU  and  optic  nerve,  a  great  quantity  of  a  thick  viscid  dark- 
brown  matter,  coloured  the  knife.  The  eyeball  and  tumour 
seemed  entirely  composed  of  a  similar  dark-coloured  matter.  This 
singular-looking  substance  was  of  the  consistence  of  thick  oil-paint, 
thongh  not  so  clammy  nor  oleaginous.  It  soiled  the  fingers  of  a 
dark  brown  or  amber  colour.  It  readily  dissolved  in  water,  and 
both  Mr.  Burns  and  Mr.  W  ardrop  were  struck  with  its  resem- 
blance to  the  pigmentum  nigrum.  The  cornea  appeared  sound, 
and  the  crystalline  lens  behind  it  was  of  an  amber  colour.  The 
sclerotica,  at  that  part  which  corresponded  to  the  malar  portion  of 
the  orbit,  was  ruptured  by  the  tumour,  and  the  torn  edges  v:ere 
separated  about  a  quarter  of  an  inch  from  one  another.  The 
sclerotica  was  at  the  same  place  split  into  two  layers,  a  small  quan- 
tity of  the  dark-coloured  substance  being  interposed  between  them. 
No  distinct  remains  could  be  traced  of  the  iris,  but  the  choroid  ap- 
peared much  more  vascular  than  natural,  and  at  one  part  a\  as  five 
or  six  times  its  usual  thickness.  At  the  place  where  the  sclerotica 
was  ruptured;  the  choroid  insensibly  terminated  in  a  white  pulpy 
substance,  composing  part  of  the  diseased  mass.  The  contents  of 
the  eyeball  were  composed  chietiy  of  a  medullary-hke  pulp}^-  sub- 
stance, variously  tinged  in  different  places  by  the  dark-brown  col- 
ouring matter.  The  tumour  projecting  beyond  the  sclerotic  coat, 
appeared  to  be  composed  of  a  similar  structure,  and  upon  macera- 


465 

tion,  numerous  white  striae,  and  in  some  places  spots,  appeared 
throughout  the  substance  of  the  diseased  mass.  Exterior  to  the 
eyeball,  the  tumour  was  covered  with  a  thick  mucous  membrane, 
except  at  the  two  small  prominent  parts  where  it  had  been  ulcer- 
ated, this  covering  being  probably  derived  from  the  conjunctiva, 
which  the  tumour  in  its  progress  had  pushed  before  it. 

The  optic  nerve  was  of  its  natural  size,  but  by  examining  its 
section,  it  was  found  that  the  medullary  part  of  it  had  a  black  ap- 
pearance, exactly  resembling  the  tumour  in  the  eyeball,  while  its 
neurilema  was  apparently  healthy.  No  remains  of  the  retina 
could  be  detected.  One  of  the  lymphatic  glands  lying  by  the  side 
of  the  optic  nerve  was  changed  into  a  dark  coloured  substance. 

Although  much  reduced  by  hectic,  and  emaciated  to  a  great 
degree  at  the  time  of  the  operation,  the  patient  soon  appeared  to 
recover ;  she  gained  flesh  and  strength,  her  appetite  was  restored, 
the  pains  in  her  back  and  loins  left  her,  she  slept  well,  and  was 
able  to  walk  about.  The  orbit  discharged  good  pus  in  moderate 
quantity,  and  was  at  last  filled  up  with  a  soft  substance,  which 
although  dark  in  colour,  skinned  over. 

When  she  and  her  friends  considered  her  recovery  certain,  the 
weather  became  cold  and  damp ;  the  pain  about  her  back  soon  re- 
curred, she  lost  her  appetite,  and  was  unable  to  walk  from  exquisite 
pains  in  the  loins.  She  could  obtain  no  sleep,  except  from  opium. 
The  lower  eyelid  was  protruded  by  an  elastic  fungus,  which  also 
began  to  project  from  between  the  lids.  The  disease  in  the  orbit 
gave  her  no  uneasiness,  her  whole  complaint  being  seated  in  the 
back  and  loins.  The  pain  there  was  so  excruciating,  and  occa- 
sionally so  much  increased  in  intensity,  that  she  screamed  from 
agony.  She  could  neither  turn  in  bed,  nor  permit  herself  to  be 
turned.  In  this  deplorable  condition,  she  lingered  for  two  or  three 
months ;  the  tumour  below  the  orbit  all  the  wliile  increasing  in 
size,  and  the  pain  in  the  loins  in  no  degree  remitting.  When  Mr. 
Burns  saw  her,  three  weeks  before  her  death,  she  was  emaciated 
to  the  last  degree.  The  tumour  below  the  orbit  was  as  large  as  a 
pullet's  egg ;  its  surface  unequal,  the  most  prominent  parts  of  it 
covered  with  livid  integuments,  and  the  swelling  conveying  to  the 
fingers  the  impression  as  if  it  contained  a  fluid.  From  between 
the  eyelids,  a  very  small  fungus  protruded,  covered  with  a  coat  of 
bloody-looking  matter.  She  had  little  or  no  pain  in  either  the 
orbit  or  the  head,  and  the  vision  of  the  other  eye  remained  unim- 
paired. From  this  time  to  her  death,  she  sunk  gradually,  the  tu- 
mour going  on  to  enlarge,  and  becoming  more  discoloured  on  its 
surface,  and  more  irregular,  but  the  fungus  between  the  lids  under- 
going no  change.  About  twenty-four  hours  previous  to  her  death, 
she  became  suddenly  comatose. 

On  dissection,  the  liver  was  found  to  contain  some  tumours  of 
a  similar  texture  and  appearance  with  the  contents  of  the  eyeball, 
as  ascertained  after  its  extirpation.  There  was  also  a  cyst  in  the 
59 


466 

substance  of  the  liver,  filled  with  a  great  quantity  of  grumous- 
looking  purulent  matter.  Above  the  kidneys  there  were  similar 
tumours  of  pretty  considerable  size,  and  the  uterus  was  cartilag- 
inous. The  urinary  bladder  was  enormously  distended  with  a 
turbid,  bloody-looking  fluid  ;  but  otherwise,  in  so  far  as  this  viscus 
was  examined,  its  structure  appeared  healthy. 

By  making  a  vertical  section  of  the  orbit  and  fungus  it  contained, 
the  tumour  was  found  to  arise  entirely  from  the  antrum  maxillare^ 
which  had  burst  both  above  and  in  front.  The  fungus  projected 
also  beyond  the  lower  spongy  bone  and  investing  membrane  of 
the  nose,  into  the  nostril.  The  tumour  proceeding  from  the  an- 
trum was,  on  its  outer  surface,  studded  over  with  small  knobs  of  a 
dark  livid  colour.  Internally,  this  tumour  was  made  up  of  a  soft 
substance  of  an  ink  colour,  intersected  by  membranous  slips,  in- 
termixed with  a  greyish  substance,  and  with  ragged  fragments  of 
bone.  The  anterior  wall  of  the  antrum  was  destroyed  at  its  upper 
part,  and  the  floor  of  the  orbit  was  elevated,  so  as  to  have  merely 
the  periosteum  and  a  thin  layer  of  fat  between  it  and  the  orbitary 
plate  of  the  frontal  bone.  The  fungus  was  exterior  to  the  orbit, 
although  from  the  destruction  of  the  periosteum  attached  to  the 
malar  portion  of  the  orbit,  it  had  been  allowed  to  protrude  from  be- 
tween the  eyelids.  This  portion  of  the  periosteum  was  partly  de- 
stroyed by  disease,  and  partly  in  conseijuence  of  the  removal  of  a 
carious  portion  of  the  bone,  when  the  eye  was  extirpated. 

With  regard  to  the  optic  nerve,  it  was  expected  that  its  extremity 
would  have  been  connected  with  the  fungus.  Between  them, 
however,  the  periosteum  of  the  floor  of  the  orbit  was  interposed. 
The  nerve  itself  was  of  its  natural  size,  but  of  a  black  colour  where 
it  entered  the  foramen  opticum.  From  this  point  to  near  where 
it  had  been  divided  in  the  extirpation  o.f  the  eyeball,  it  was  in  a 
similar  state ;  the  neurilema  had  only  a  slight  connexion  with  the 
diseased  substance  of  the  nerve.  At  the  bottom  of  the  orbit  there 
was  considerable  matting  and  induration  of  the  origin  of  the  mus- 
cles. At  its  termination  the  nerve  formed  a  sharp  point,  its  coats 
adhering  to  the  thickened  periosteum  of  the  floor  of  the  orbit,  which 
was  pressed  in  contact  with  it  by  the  fungus  from  the  antrum. 
The  optic  nerve  within  the  cranium  was  as  thick  as  the  little 
finger,  and  as  dark  in  colour  as  the  part  of  it  contained  in  the  orbit. 
The  junction  of  the  nerves  was  so  much  enlarged,  that  it  formed 
a  tumour  extending  into  the  third  ventricle. 

As,  from  the  dark  colour  of  the  diseased  parts,  this  was  a  fa- 
vourable opportunity  for  ascertaining  whether  the  optic  nerves 
decussate,  or  merely  unite,  the  state  of  these  parts  was  carefully 
examined.  The  dark  colour  w^as  found  to  extend  much  beyond 
the  point  where  the  nerves  join  ;  but  this  change  of  colour  was 
confined  to  the  left  side,  or  to  the  nerve  of  the  affected  eye.  On 
the  right  side,  the  nerve  was  of  its  natural  size  and  colour,  and 
was    attached    to   the  black   diseased   parts  merely  by   cellular 


467 

shreds.  This  dissection,  therefore,  clearly  proved,  that  the  nerves 
did  not,  in  this  individual,  cross  each  other. 

Case  2.  In  January,  1824,  Thomas  Peckett,  aged  30,  a  robust 
healthy-looking  rnan,  consulted  Mr.  Wilson  of  Manchester,  respect- 
ing a  violent  and  incessant  pain  in  his  left  eye.  Six  months  pre- 
vious to  his  application,  he  had  received  a  blow  upon  the  organ, 
from  the  projection  of  a  small  piece  of  iron  ;  but  the  injury  appeared 
to  be  of  a  very  trifling  nature,  as  he  experienced  but  little  pain, 
and  the  eye  did  not  exhibit  any  external  appearance  to  attract  the 
notice  of  others.  About  a  fortnight  after  this  accident,  he  experi- 
enced a  sensation  of  fulness  in  the  globe,  and  upon  shutting  his 
right  eye,  discovered  that  his  sight  in  the  left  was  very  imperfect. 
The  pain  and  dimness  gradually  increased,  the  former  to  a  most 
distressing  degree,  affecting  chiefly  the  ball  of  the  eye  and  margin 
of  the  orbit. 

The  conjunctival  vessels  were  now  enlarged  and  tortuous,  and 
the  sclerotica  generally  inflamed  and  undergoing  absorption,  the 
dark  choroid  being  just  visible  towards  the  internal  canthus.  The 
iris  was  immovable,  and  a  slate-coloured  opacity  occupied  the  cen- 
tre of  the  dilated  pupil.  No  symptoms  of  cerebral  affection  were 
manifested.  The  treatment  had  been  limited  to  the  occasional  ap- 
plication of  leeches  to  the  temple. 

By  drawing  blood  freely  and  repeatedly  from  the  temple  and 
nape  of  the  neck,  together  with  bHstering,  active  cathartics,  and  an 
abstemious  diet,  the  pain  was  removed  ;  but  no  amendment  in 
vision  ensued.  At  this,  however,  he  was  not  disappointed,  as 
Mr.  Wilson  had  given  him  no  reason  to  hope  that  his  sight  would 
be  restored.  After  remaining  in  Manchester  nearly  a  month,  he 
was  permitted  to  return  into  Staffordshire. 

Towards  the  end  of  March,  he  again  applied  on  account  of  a 
return  of  pain.  He  stated,  that  a  few  days  after  he  returned  home, 
he  had  experienced  his  former  sensations,  and  the  pain  was  now 
so  violent  and  incessant,  as  to  prevent  him  from  sleeping.  The 
disease  had  made  considerable  progress,  and  it  was  to  be  feared, 
that  the  pain  was  owing  to  a  morbid  growth  within  the  eye. 
The  sclerotica,  at  its  upper  part  and  towards  the  inner  canthus, 
was  extremely  extenuated  ;  the  choroid  covering  the  protruding 
substance.  The  opaque  appearance  in  the  pupil  had  assumed  a 
dirty  red  colour,  resembling  newly  organized  lymph,  and  this 
seemed  to  be  the  apex  of  a  conical-shaped  body,  situated  deep  in 
the  bottom  of  the  eye. 

The  former  treatment,  with  moderate  ptyalism,  was  ineffectually 
adopted,  and  on  the  19th  of  April,  Mr.  Wilson  removed  the  contents 
of  the  orbit. 

A  section  of  the  eyeball  discovered,  in  the  situation  of  the  vit- 
reous humour,  a  black  pultaceous  tumour,  occu|)ying  more  than 
one-half  of  the  interior  of  the  globe.  There  were  two  cavities  or 
cells  filled  with  a  brownish-red  fluid,  one  situated  at  the  side  of  the 


468 

tumour,  the  other  anterior  to  it,  and  behind  the  lens.  No  trace 
of  the  vitreous  humour  or  cells  could  be  discovered.  The  choroid 
was  entire,  and  could  easily  be  separated  from  the  sclerotica,  except 
at  one  point  towards  its  superior  and  internal  part,  where  it  ceased 
to  be  distinguishable  from  the  general  mass  of  the  tumour.  The 
sclerotica  was  here  reduced  to  an  extreme  degree  of  tenuity,  and 
had  a  split  appearance.  The  retina  was  quite  detached  from  the 
choroid  by  the  interposition  of  the  disease,  and  lay  folded  across 
the  globe,  forming  a  kind  of  septum  between  the  black  mass  and 
the  larger  of  the  two  cavities,  containing  the  brownish-red  fluid. 
The  lens  was  opaque  and  of  a  yellow  hue,  the  capsule  thickened, 
but  partially  transparent ;  a  fold  of  retina  covered  the  posterior  cap- 
sule. The  ciliary  ligament  was  distinct,  and  some  ragged  portions 
of  membrane  at  the  margin  of  the  lens,  and  posterior  to  the  iris, 
which  was  perfect,  showed  a  remnant  of  the  cihary  processes. 
The  optic  nerve,  where  it  had  been  divided  at  the  time  of  the 
operation,  appeared  to  be  sound. 

He  recovered  from  the  operation,  and  returned  home  at  the  end 
of  a  month,  apparently  well. 

In  August  he  again  applied,  on  account  of  three  or  four  tumours 
on  the  face,  about  the  size  of  leaden  shot,  perfectly  black,  but  unat- 
tended by  uneasiness.  He  complained  of  difficulty  of  breathing  and 
stitches  in  his  side,  with  a  short  cough.  He  had  evidently  wasted 
in  flesh,  and  his  pulse  was  quick  and  remarkably  sharp.  A  tumour 
similar  to  those  on  the  face,  was  discovered  on  the  skin  of  the  back, 
between  the  scapulae.  In  a  few  days,  one  or  more  were  found  on 
the  scalp. 

His  strength  rapidly  decHning,  he  came  under  the  care  of  Mr. 
Fawdington  on  the  2d  of  October.  His  general  aspect  indicated  a 
deficient  supply  of  nutriment,  or  an  imperfect  appropriation  of  it 
to  the  purposes  of  the  system.  The  surface  of  his  body  was  pale 
and  exsanguineous,  and  there  was  a  considerable  degree  of  muscu- 
lar emaciation,  with  oedema  of  the  legs.  But  the  most  striking 
feature  of  the  case  was  an  exceedingly  protuberant  abdomen,  ap- 
parently from  enlargement  of  one  of  its  viscera,  and  this  probably 
the  liver.  The  face  and  scalp  displayed  several  perfectly  developed 
melanose  tubercles,  and  one  on  the  lower  lid  of  the  extirpated  eye 
appeared  on  the  verge  of  ulceration.  The  bottom  of  the  orbit  was 
free  from  any  visible  melanose  deposition.  In  every  other  situa- 
tion, excepting  two  or  three  points  on  the  trunk,  the  cutis  had  es- 
caped the  direct  invasion  of  the  disease ;  but  the  subcutaneous 
tissue,  over  the  whole  chest  and  abdomen,  was  evidently  loaded 
with  melanosis,  giving  rise,  where  the  cysts  encroached  on  the 
skin,  to  faint- blue  elevations,  more  or  less  distinct,  and  of  various 
sizes  ;  none,  however,  exceeding  the  fourth  of  an  inch  in  diame- 
ter. 

The  patient  died  on  the  3d  of  November,  worn  out  by  hectic. 

On  dissection,  the  subcutaneoue  cellular  texture  on  the  front  of 


469 

the  trunk  was  found  granulated  with  melanose  tubercles.  The 
liver,  enlarged  to  four  times  its  natural  size,  was  disorganized  by 
the  same  disease ;  with  which  also  the  peritoneum,  pancreas,  spleen, 
kidneys,  pleurae,  lungs,  and  heart,  were  more  or  less  affected.  The 
brain  was  not  examined.* 

Causes  and  Treatment.  As  to  the  remote  and  exciting  causes 
of  melanosis,  we  are  quite  in  the  dark ;  nor  can  we  say  any  thing 
with  certainty  on  the  methodus  medendi. 


I 


SECTION    VIIT. EXTIRPATION  OF  THE  EYEBALL. 

1.  In  this  operation,  it  is  preferable  to  lay  the  patient  along  on 
his  back,  with  his  head  raised  on  a  pillow,  rather  than  keep  him  in 
the  sitting  position.  If  a  child,  he  may  be  laid  across  the  knees  of 
one  of  the  assistants,  who  is  to  hold  him  by  the  elbows  and  trunk  ; 
while  another  assistant,  with  his  knees,  fixes  the  child's  head. 

2.  When  the  eyeball  is  not  enlarged,  it  in^y  be  removed  without 
any  previous  separation  of  the  lids  from  each  other  at  their  tempo- 
ral angle.  But  if,  on  the  contrary,  there  is  any  considerable  en- 
largement of  the  eyeball,  it  is  absolutely  necessary  first  to  effect 
such  a  separation  of  the  lids,  by  means  of  an  incision  carried  out- 
wards from  their  external  angle,  towards  the  temple.  Even  when 
the  eye  is  small,  such  separation  of  the  lids  enables  the  operator  to 
accomplish  the  extirpation  of  the  eye  with  much  greater  facility. 
Nor  does  it  leave  any  additional  deformity,  for  the  edges  of  the  in- 
cision are  brought  togejher  immediately  after  the  operation  is  fin- 
ished, and  generally  adhere  by  ihe  first  intention.  Care  must  be 
taken  in  making  this  separation  of  the  lids,  not  to  Hmit  the  incision 
to  the  skin  merely,  but  to  go  through  the  fibrous  layer  of  the  lids, 
and  the  conjunctiva,  so  that  the  eyeball  may  be  easily  and  fully  ex- 
posed. 

3.  The  operator  now  passes  a  large  curved  needle,  armed  with 
a  strong  linen  thread,  double  and  waxed,  through  the  eyeball, 
from  its  temporal  to  its  nasal  side,  avoiding  the  cornea,  and  any 
part  which  appears  to  be  so  disorganized  that  it  would  give  way  un- 
der traction  of  the  ligature.  The  needle  is  then  cut  away,  and  the 
ends  of  the  thread  knotted  together.  By  means  of  the  thread, 
the  eye  can  be  carried  in  any  particular  direction  during  the  re- 
maining steps  of  the  operation.  Some  prefer  a  large  sharp  hook 
for  the  same  purpose. 

4.  The  eye  being  carried  upwards  and  outwards,  the  operator 
plunges  a  double-edged  scalpel  directly  backwards  into  the  orbit, 
between  the  eyeball  and  the  internal  canthus,  and  then  sweeping 
the  instrument  round,  he  separates  the  eyeball  from  the  lower  eye- 
lid, by  a  division  of  the  conjunctiva.  Next,  dragging  the  eye  in- 
wards and  downwards,  while  one  of  the  assistants  elevates  the  up- 

*  Case  of  Melanosis,  by  Thomas  Fawdington.    London,  1^6. 


470 

per  eyelid,  the  connexion  of  the  upper  part  of  the  conjunctiva  is 
disunited,  the  scalpel  passing  round  the  eyeball  to  the  inner  can- 
thus.  The  cellular  connexions  of  the  muscles  of  the  eyeball  with 
the  walls  of  the  orbit  are  next  to  be  divided,  and  the  inferior  ob- 
lique muscle  cut  across,  bearing  carefully  in  mind  the  directions  of 
the  sides  of  the  orbit,  and  the  thinness  of  its  roof.  The  optic 
nerve  at  last  forms  the  only  remaining  connexion  which  prevents 
the  complete  extirpation  of  the  eye.  Dragging  the  eye  forward  by 
means  of  the  ligature  or  the  hook,  the  nerve,  thus  put  on  the 
stretch,  is  to  be  divided  with  the  strong  curved  scissors  recom- 
mended for  this  purpose  by  Louis,  and  commonly  called  Louis's 
scissors. 

5.  As  soon  as  the  bleeding  from  the  trunk  of  the  ophthalmic 
artery  has  ceased,  which  it  commonly  does  either  spontaneously,  or 
after  throwing  a  little  cold  water  into  the  orbit  by  means  of  a  gum- 
elastic  bottle,  the  operator  examines  the  orbit  with  his  index-finger, 
in  order  to  discover  whether  any  of  the  diseased  substance  be  left 
behind.  If  there  is  any  such,  it  must  be  dissected  away.  The 
lachrymal  gland  also,  even  when  not  diseased,  it  to  be  laid  hold  of 
with  a  pair  of  forceps,  and  removed  with  the  scissors. 

6.  It  was  formerly  the  common  practice,  after  this  operation,  to 
stuff  the  orbit  with  hnt,  rolled  up  into  a  ball,  and  surrounded  by  a 
thread,  which  was  left  hanging  from  between  the  eyelids.  This 
is  now  laid  aside.  The  lids  are  merely  brought  together,  and  cov- 
ered with  a  piece  of  spread  lint,  a  light  compress,  and  a  roller.  If 
the  lids  have  been  separated  by  an  incision  carried  from  their  outer 
angle  towards  the  temple,  the  edges  of  this  wound  are  to  be  brought 
into  contract,  and  kept  so  by  a  suture. 

7.  As  for  the  haemorrhage  which  occurs  during  or  after  this  ope- 
ration, the  free  exposure  of  the  bleeding  vessels  to  the  air  for  a  few 
seconds,  or  the  injection  of  cold  water  into  the  orbit,  is  in  general 
sufficient  to  produce  their  contraction.  We  are  of  course  provided, 
however,  with  the  tenaculum,  and  ought  to  tie  any  considerable 
vessel  within  reach,  which  may  still  continue  to  bleed.  If  bleeding 
goes  on  to  any  considerable  extent  from  the  deep  part  of  the  orbit, 
pressure  must  be  had  recourse  to.  Sometimes  the  mere  pressure  of 
the  finger  for  a  few  minutes  is  sufficient,  but  in  other  cases,  it  is  ne- 
cessary to  introduce  into  the  orbit,  a  roll  of  lint,  against  which  the 
lids  being  compressed  by  a  bandage  going  round  the  head,  the  bleed- 
ing is  completely  checked.  The  roll  of  lint  may  be  left  in  the  or- 
bit for  five  or  six  days. 

9.  It  occasionally  happens  that  the  disease  of  the  eyeball  has 
propagated  itself  to  the  eyelids,  and  that  they  are  either  adhe- 
rent to  the  eyeball,  present  a  number  of  irregular  prominences  and 
fungosities,  or  have  become  affected  with  ulceration.  In  such  cir- 
cumstances, it  ma}^  be  judged  necessary  to  remove  the  eyelids  as 
well  as  the  eyeball.  In  this  case,  we  commence  the  operation  by 
the  removal  of  the  lower  lid,  then  extirpate  the  ball,  and  if  it  be 


i 


471 

necessary  to    take  away  the  upper  lid  also,  terminate  with  its 
removal. 

9.  The  patient  must  be  kept  quiet,  fed  on  spoon-diet,  and  his 
bowels  carefully  attended  to.  In  general,  no  bad  effects  follow 
the  operation.  The  clotted  blood  which  fills  the  orbit  dissolves,  the 
periosteum  discharges  pus,  granulation  follows,  and  the  cavity  is 
partly  filled  by  newly-forrned  vascular  substance.  It  sometimes 
happens,  hovi^ever,  especially  if  lint  has  been  left  within  the  orbit, 
that  violent  inflammation  ensues,  followed  by  suppuration,  within 
that  cavity,  in  the  eyelids,  or  the  integuments  of  the  forehead,  or 
even  withia  the  cranium.  Mr.  Travers  mentions  that  he  lost  a  pa- 
tient, a  middle-aged  countryman,  otherwise  in  health,  within  a  fort- 
night after  this  operation,  owning  to  a  suppuration  of  the  dura  mater, 
on  the  same  side  of  the  head.  The  attack  of  inflammation  was 
sudden  and  rapid,  commencing  about  a  week  after  the  operation, 
and  ushered  in  by  a  severe  rigor,  after  imprudent  exposure  to  cold.* 


CHAPTER  XIV. 

CATARACT.f 


SECTION      1. DEFINITION      AND      DIAGNOSIS      OF      CATARACT  ; 

METHOD    OF    EXAMINING    CASES    OF    THIS    DISEASE  ;    CAUSES 
AND  PROGNOSIS. 

The  name  cataract  is  bestowed  on  any  opacity  situated  between 
the  vitreous  humour  and  the  pupil. 

Enumerating  the  parts  so  situated,  we  have  first,  the  posterior 
hemisphere  of  the  crystalline  capsule  ;  secondly,  the  crystalline 
lens  ;  and  thirdly,  the  anterior  hemisphere  of  the  crystalline  cap- 
sule. Any  of  these  parts  may  become  opaque,  and  will  constitute 
a  capsular  or  a  lenticular  cataract,  according  as  the  opacity  is  seated 
in  the  capsule  or  the  lens.  Between  the  internal  surface  of  the 
capsule,  and  external  surface  of  the  lens,  there  exists,  in  the  natu- 
ral state,  a  considerable  degree  of  adhesion,  but  in  consequence  of 
disease,  an  opaque  fluid  is  sometimes  effused  within  the  capsule,  so 
as  to  separate  it  from  its  natural  cohesion  with  the  lens,  and  form 
what  is  termed  a  Morgagnian  cataract.  Any  opacity  situated  in 
or  within  the  crystaUine  capsule,  is  termed  a  true  cataract^  and 
it  is  evident  that  all  those  above  enumerated,  fall  under  this  de- 
nomination. 

**  Synopsis  of  the  Diseases  of  the  Eye,  p.  309.     London,  1820. 

t  From  KcfrcLggiLo-a-ie,  to  break,  or  disturb ;  vision  being  broken,  or  disturbed  by  this 
disease.  Txa.v^ai/mct  of  Hippocrates.  TvoyvfAit  of  Galen.  Suffusio  of  Celsus.  Gutta 
opaca  of  the  Arabians.    Caligo  Lentisoi  Cullen. 


472 

Between  the  anterior  crystalline  capsule  and  the  pupil  lies  the 
aqueous  humour  of  the  posterior  chamber.  This  cannot  become 
opaque  without  the  whole  of  the  aqueous  humour  being  similarly  af- 
fected ;  but  it  may  be  displaced  by  an  opaque  substance  ;  as,  co- 
agulated lymph.  Such  a  cataract  as  this  is  termed  spitrious,  and 
has  its  seat  loithout  the  capsule. 

When  the  term  cataract  is  used  without  any  appellative,  lenticu- 
lar opacity  is  generally  meant.  For  instance,  when  we  say  that 
cataract  is  a  slow  disease,  occupying  one,  two,  or  more  years  in  its 
progress,  it  is  of  lenticular  cataract  that  we  speak  ;  for  all  the  oth- 
ers, and  especially  the  spurious  cataracts,  may  be  the  product  of  a 
few  days,  or  hours.  It  sometimes  happens,  however,  that  even 
lenticular  cataract  is  fully  developed  in  a  very  short  space  of  time. 
I  had  lately  a  patient  attending  at  the  Eye  Infirmary,  with  glau- 
coma and  amaurosis  of  one  eye,  but  without  any  affection  of  the 
lens.  She  was  present  as  usual,  on  a  Monday  or  Wednesday,  the 
eye  exhibiting  exactly  the  appearances  which  it  had  done  for  some 
months  before.  On  the  Friday,  I  was  surprised  to  find  the  lens 
completely  opaque,  and  stellated  by  radiating  lines,  running  from 
its  centre.  Richter,  however,  relates  a  still  more  remarkable  case, 
in  which  cataract  was  completely  formed  in  the  course  of  one 
night.  A  patient  who  had  been  labouring  under  gout,  had  his 
feet  exposed  to  a  great  degree  of  cold  during  the  night,  in  conse- 
quence of  which,  the  gout  suddenly  retroceded,  and  he  was  entirely 
deprived  of  his  sight.  Richter  saw  him  next  morning,  and  found 
a  complete  pearly-coloured  cataract.*  Mr.  Wathen  was  of  opinion 
that  blacksmiths,  and  all  mechanics  who  work  near  large  fires, 
were  more  subject  to  cataracts  than  other  persons,  and  he  men- 
tions that  he  had  had  two  patients  who  were  instantly  seized  with 
cataract,  at  the  very  time  they  were  thus  employed. t 

Diagnosis.  It  is  of  much  importance  that  we  should  distin- 
guish incipient  cataract  from  incipient  amaurosis.  In  the  fully  de- 
veloped state,  these  two  diseases  can  scarcely  be  confounded  by  any 
one  in  the  least  acquainted  with  the  diseases  of  the  eye  ;  but  in  the 
early  stages,  such  a  mistake  n^say  readily  be  fallen  into,  and  may 
be  productive  of  very  serious  bad  effects.  For  example,  if  a  pa- 
tient with  incipient  amaurosis  present  himself  to  a  practitioner  who 
mistakes  the  case,  and  supposes  it  to  be  one  of  incipient  cataract, 
the  advice  which  he  will  very  probabh'  give,  will  be  to  wait  with 
patience  till  the  disease  be  fully  developed,  and  then  to  submit  to 
an  operation  for  its  removal.  Should  the  patient  return  after  some 
months  with  a  fully  developed  amaurosis,  instead  of  a  cataract,  the 
practitioner  would  necessarily  feel  that  he  had  allowed  the  only 
season  for  treating  an  amaurotic  affection  with  success  to  pass  un- 
employed ;  and  thus,  by  his  ignorance  or  inattention,  probably  de- 
prived his  patient  of  all  hope  of  regaining  sight. 

*  Treatise  on  the  Extraction  of  the  Cataract;  translated  from  the  German;  p.  3» 
London  1791. 
t  Dissertation  on  the  Theory  and  Cure  of  the  Cataract ;  p.  12.    London  1785. 


473 

The  symptoms  of  cataract  and  amaurosis,  as  indeed  of  all  dis- 
eases whatever,  are  subjective  or  objective  ;  that  is  to  say,  they 
consist  either  in  certain  changes  which  the  patient  experiences,  as 
impaired  vision,  headach,  giddiness,  &c.,  or  in  certain  changes 

,  which  we  discover  in  the  form,  colour,  texture,  consistency,  vas- 
cularity, and  mobility  of  the  different  parts  of  the  organ  of  vision. 

:  Both  sets  of  symptoms  will  require  to  be  very  closely  examined  in 
suspected  cases  of  incipient  cataract  or  amaurosis. 

1.  As  to  the  impaired  state  of  vision  which  attends  both  these 
diseases  in  the  incipient  stage,  the  patient  affected  with  either  of 
them,  finds  a  difficulty  in  discerning  objects  with  distinctness.  In 
cataract,  this  difficulty  increases  very  slowly,  and  is  compared  to 
what  might  be  produced  by  a  diffused  mist,  thin  cloud,  or  gauze, 
intervening  between  the  object  and  the  eye  :  whereas  in  amauro- 
sis, the  dimness  of  sight  is  often  sudden,  and,  being  partial,  is 
compared  to  a  fly,  or  other  small  black  spot  or  spots,  covering  cer- 

I  tain  parts  of  an  object.     It  is  a  fact,  however,   and   one  which 
strikingly  illustrates  the  uncertainty  which  attends  the  diagnosis  of 
'  cataract  and  amaurosis,  that  muscse  volitantes,  as  the  appearance 
I  of  dark  spots  before  the  eye  has  been  termed,  are  sometimes  a  pre- 
I  cursor  of  cataract,  while  in  other  cases,  this  symptom  continues 
for  many  years,  without  ending  either  in  the  one  or  other  of  these 
!  diseases  ;  and  that  on  the  other  hand,  amaurosis  not  unfrequently 
declares  itself  in  the  early  stage  by  the  sensation  of  a  gauze  or 
mist,  which  slowly  increasing  in  density,  at  length  totally  deprives 
the  patient  of  sight.     So  complete  a  degree  of  blindness  never  oc- 
curs in  cataract.     That,  however,  is  of  little  consequence,  so  far 
as  our  present  object  is  concerned,  namely,  the  diagnosis  in  the 
incipient,  not  in  the  advanced  stage. 

2.  As  the  diminution  of  vision  accompanying  incipient  cataract 
depends  on  the  lens  becoming  opaque,  and  as  this  opacity  gener- 
ally commences  in  the  centre  of  the  lens,  we  almost  always  find 
that  the  sensation  of  a  mist  or  cloud  is  perceived  most  when  the 
patient  looks  straight  forward,  rendering  indistinct  those  objects 
chiefly  which  are  placed  directly  in  front.  He  sees  considerably 
better  when  he  looks  sideways.  This  circumstance  might  appear 
likely  to  afford  ground  for  distinguishing  incipient  cataract  from 
amaurosis,  were  it  not  well  ascertained,  that  those  also  who  begin 
to  be  affected  with  diminished  sensibiUty  of  the  retina,  are  in  many 
instances  able  to  see  objects  placed  to  one  side,  much  better  than 
those  which  stand  directly  before  them ;  and  that  some,  in 
whom  amaurosis  is  even  far  advanced,  continue  to  see  only  when 
they  look  inwards  or  outwards,  while  in  every  other  direction,  ob- 
jects are  seen  very  obscurely,  or  not  at  all. 

3.  The  different  degrees  of  light  in  which  those  affected  with 
incipient  cataract  or  amaurosis  see  best,  is  worthy  of  attention.  In 
those  cases  in  which  vision  begins  to  fail  from  diminished  sensibil- 
ity of  the  retina,  there  is  in  general  a  constant  desire  for  an  increase 

60 


474 

of  light ;  when  the  patient  reads  with  candle-hght,  he  brings  the 
book  as  close  as  he  can  to  the  candle ;  and  his  period  of  most 
distinct  vision  is  noon-day,  when  objects  are  most  brilliantly  illu- 
minated by  the  sun.  This  is  the  very  time  when  the  cataract  pa- 
tient sees  worst.  So  much  hght  causes  the  pupil  to  contract ; 
any  of  the  rays  of  light  which  enter  his  eye,  must  pass  through 
the  opaque  central  portion  of  the  lens  ;  this  they  do  with  diffi- 
culty, and  hence  vision  is  obscure ;  but  in  the  twilight,  when 
the  pupil  is  dilated,  the  light  penetrating  through  the  transparent 
edge  of  the  lens,  the  patient  with  incipient  cataract  finds  his 
vision  greatly  improved.  To  witness  the  effects  of  moderating  the 
intensity  of  the  light  to  which  his  eye  is  exposed,  and  thus  al- 
lowing a  greater  quantity  of  it  to  penetrate  to  the  retina,  we  re- 
quire only  to  make  him  look  to  and  from  the  window.  In  the 
former  position,  he  sees  perhaps  very  little  ;  but  turn  his  back  to 
the  light,  and  he  instantly  discerns,  more  or  less  distinctly,  every 
object  around  him.  Yet  even  this  must  not  be  absolutely  de- 
pended on.  We  meet  with  amaurotic  patients,  to  whom  strong 
light  is  distressing,  and  w^ho  see  best  under  a  moderate  degree 
of  illumination. 

4.  It  is  rarely  the  case  that  incipient  amaurosis  is  not  attended 
by  a  variety  of  other  symptoms  besides  failure  of  sight ;  especially 
by  headach,  vertigo,  and  derangement  of  the  digestive  organs.  In- 
cipient lenticular  cataract  most  frequently  occurs  without  any  such 
combination  of  complaints. 

5.  Having  carefully  considered  the  account  which  the  patient 
gives  us  of  w^iat  he  himself  has  experienced,  we  turn  to  the  symp- 
toms which  are  more  strictly  objects  for  our  observation,  and  ex- 
amine first  of  all  whether  there  is  any  opacity  visible  through  the 
pupil,  and  if  there  is,  endeavour  to  ascertain  its  seat,  or  its  nature. 

It  is  rarely  the  case  even  in  incipient  amaurosis,  that  the  pupil 
presents  the  jet-black  colour  of  health.  The  appearance,  however, 
is  not  so  much  an  actual  opacity,  as  a  paleness,  or  greenishness, 
discerned  only  when  the  eye  is  regarded  in  certain  directions,  and 
which  we  know  to  be  the  result  of  the  light  being  reflected  from  a 
diseased  choroid.  This  symptom  is  what  we  now  term  glaucoTnay 
which  has  by  mistake  been  commonly  attributed  to  opacity  of  the 
vitreous  humour.  Repeated  dissections  of  the  eye  in  the  state  of 
glaucoma  have  convinced  me,  that  deficiency  of  the  pigmentum 
nigrum  is  the  cause  of  this  symptom,  which  is  often  attended,  no 
doubt,  by  dissolution  of  the  hyaloid  membrane,  and  sometimes  by 
yellowness  of  the  centre  of  the  lens. 

To  distinguish  incipient  amaurosis  with  glaucoma,  from  incip- 
ient cataract,  proves  to  beginners  one  of  the  most  difficult  pieces  of 
diagnosis,  and  sometimes  not  to  beginners  only,  but  to  those  who 
for  a  length  of  time  have  attended  to  the  diseases  of  the  eye. 
About  ten  years  ago,  a  gentleman  was  sent  to  me  by  his  brother, 
a  medical  practitioner  in  the  country,  desirous  to  know  if  I  thought 


475 

the  cataracts,  which  he  said  I  would  see  in  his  eyes,  were  ready 
for  operation.  The  disease  was  glaucoma,  with  a  great  degree  of 
shortness  of  sight,  but  without  any  disease  of  the  lens.  With 
much  difficulty  could  I  convince  the  brother  of  the  real  nature  of 
the  case,  so  wedded  was  he  to  the  opinion  that  the  opacity  which 
he  saw  through  the  pupil,  was  cataract.  The  eyes  of  this  patient 
continue  at  this  day  very  nearly  in  the  same  state.  I  could  men- 
tion many  similar  cases. 

Attention  to  the  following  circumstances,  will  in  general  enable 
the  careful  observer  to  discriminate  between  glaucomatous  amauro- 
sis and  cataract. 

First,  The  opacity  in  glaucoma  is  always  greenish,  whereas,  in 
incipient  cataract,  it  is  greyish. 

Secondly,  In  glaucoma,  the  opacity  appears  to  be  seated  at  a 
considerable  distance  behind  the  pupil,  or  even  deep  in  the  vitreous 
humour ;  whereas,  in  lenticular  cataract,  it  is  evident  that  the 
opacity  is  close  behind  the  pupil.  In  posterior  capsular  cataract, 
the  opacity  is  deep  in  the  eye,  but  is  always  streaked ;  whereas, 
the  glaucomatous  reflection  is  always  uniform,  never  spotted,  nor 
radiated. 

Thirdly,  When  we  examine  narrowly  the  surface  of  a  lenticu- 
lar opacity,  especially  while  concentrating  the  light  upon  it  by 
means  of  a  double-convex  lens,  it  is  seen  to  be  slightly  rough,  and 
somewhat  dull,  never  smooth  or  polished,  in  these  respects  forming 
a  striking  contrast  to  the  appearances  presented  by  a  glaucomatous 
opacity.  Speaking  of  glaucoma,  Maitre-Jan  justly  remarks,  that 
"les  cataractes  luismites  sont  toujours  tres  suspectes."* 

Fourthly,  The  eyeball,  in  glaucomatous  amaurosis,  always  feels 
firmer  than  natural ;  while  in  cataract,  it  presents  its  usual  degree 
of  resistance  to  the  pressure  of  the  finger. 

Fifthly,  Glaucoma  proceeds  very  slowly  in  its  course.  Years 
pass  over  without  much  more  opacity  than  what  was  at  first  ob- 
served, and  with  little  or  no  farther  loss  of  sight ;  while  in  cataract, 
vision  rapidly  declines,  keeping  pace  with  the  growing  opacity. 

6.  The  mobility  of  the  iris  affords  a  valuable  ground  for  diagno- 
sis ;  for  in  incipient  cataract,  the  pupil  contracts  and  expands  as 
extensively  and  as  vividly  as  in  the  healthy  state  of  the  eye,  where- 
as in  incipient  amaurosis,  if  the  pupil  is  not  already  dilated  and 
fixed,  its  motions  are  always  limited  and  slow. 

7.  There  are  few  cases  of  amaurosis,  even  in  the  incipient  stage, 
in  which  the  natural  movements  of  the  eyeball  and  eyehds  are 
perfectly  retained.  No  impediment  of  this  kind  is  present  in  cata- 
ract; the  patient  opens  the  eyes,  and  turns  them  towards  objects, 
without  the  least  difficulty.  But  in  almost  all  cases  of  amaurosis, 
we  may  observe  a  want  of  direction  in  the  eyes,  or  a  shght  degree 
of  stralDismus,  and  not  unfrequently  an  imperfect  power  over  the 
motions  of  the  upper  lid. 

•  Traite  des  Maladies  de  I'CEil,  p.  225.     Troyes,  1711. 


476 

Circumstances  to  he  attended  to  in  cases  of  cataract.  To 
ascertain  with  accuracy  the  existence  of  cataract,  and  the  nature 
of  any  cataract  which  may  present  itself,  it  is  necessary  to  attend 
minutely  to  the  following  circumstances. 

1.  The  opacity ;  its  colour,  extent,  form,  and  seat.  Whiteness 
denotes  either  a  dissolved  lens,  or  a  capsular  cataract ;  greyness,  a 
lenticular  cataract ;  amber,  or  dark  greyness,  that  the  lens  is  hard  ; 
light  greyness,  that  it  is  soft.  If  the  whole  extent  of  the  pupil  is 
uniformly  opaque,  the  cataract  is  probably  lenticular  ;  if  the  opacity 
is  streaked  or  speckled,  it  is  probably  capsular.  If  the  opaque 
streaks  radiate  from  a  centre,  the  posterior  hemisphere  of  the  cap- 
sule is  probably  the  seat  of  the  disease.  If  the  form  of  the  opacity 
is  convex,  the  anterior  capsule  or  the  lens  is  the  part  affected  ;  if 
concave,  the  posterior  capsule.  With  the  light  concentrated  on 
the  pupil,  by  means  of  a  double-convex  glass,  all  these  particulars 
are  carefully  to  be  investigated. 

2.  The  iris  is  to  be  examined  ;  its  colour,  mobility,  form,  situa- 
tion, and  the  shadow  it  throws  upon  the  cataract.  Is  it  green,  or 
otherwise  discoloured,  denoting  previous  inflammation,  which  may 
have  left  the  eye  in  a  state  unfavourable  for  any  operation  ?  Cov- 
ering the  eye  which  we  are  not  examining,  that  all  sympathetic 
motion  of  the  iris  may  be  avoided,  we  next  examine  whether  the 
pupil  moves  rapidly,  and  extensively,  as  in  health  ;  or  slowly,  and 
to  a  very  limited  degree,  so  as  to  lead  to  the  suspicion  of  the  retina 
being  imperfectly  sensible.  Is  the  pupil  fixed,  and  irregular,  as  if 
bound  to  the  capsule  by  adhesion,  in  consequence  of  effused  lymph ; 
or  does  it  tremble  on  every  motion  of  the  head,  denoting  a  peculiar 
paralytic  state  of  the  iris,  attended  by  an  inordinate  quantity  of 
aqueous  humour  in  the  posterior  chamber,  and  generally  by  amau- 
rosis ?  Is  the  iris  convex,  and  nearer  to  the  cornea  than  natural, 
an  unfavourable  circumstance  for  the  operation  of  extraction  ?  Is 
the  shadow  thrown  by  the  iris  on  the  opaque  body  distinct,  or  is 
there  no  shadow  ?  This  depends  on  the  distance  of  the  opaque 
body  from  the  iris  ;  or,  in  other  words,  the  depth  of  the  posterior 
chamber.  If  there  is  no  shadow,  the  posterior  chamber  is  probably 
obliterated  by  the  pressure  of  a  large  and  soft  lenticular  cataract.  If 
the  shadow  is  distinct,  the  lens  is  probably  small  and  hard. 

3.  The  eyeball  in  general  deserves  attention  ;  its  colour,  degree 
of  firmness,  size,  and  place  in  the  orbit.  A  dirty  yellow  colour  of 
the  sclerotica  marks  general  ill  health,  which,  of  course,  is  unfa- 
vourable for  attempting  a  cure  by  operation.  A  boggy  eye  marks 
deficiency  of  vitreous  humour,  attended  by  amaurosis.  A  stony 
hardness  of  the  eye  denotes  glaucoma,  with  a  superabundance  of 
dissolved  vitreous  humour.  An  eye  considerably  below  the  medi- 
um size  never  recovers  any  useful  degree  of  sight.  A  very  prom- 
inent, or  a  very  sunk  eye,  is  unfavourable  for  extraction.  In  the 
latter  case,  that  operation  can  scarcely  be  performed.  In  the  for- 
mer, the  lower  lid  is  extremely  apt  to  intrude  between  the  lips  of 
the  wound  of  the  cornea,  and  keep  it  from  healing. 


477 

4.  The  degree  of  vision  must  carefully  be  noted,  both  as  denot- 
ing the  sentient  state  of  the  retina,  and  serving  to  determine  the 
propriety  of  an  immediate  operation.  If  the  patient  can  distinguish 
objects,  while  regarding  them  with  his  back  turned  to  the  light, 
the  operation  ought  to  be  deferred  till  the  sight  is  more  obscured. 
If  he  distinguishes  merely  the  shadow  of  the  fingers,  while  they 
are  moved  across  between  him  and  the  light,  the  retina  is  sensible, 
and  the  operation  may  be  performed  with  the  prospect  of  restoring 
an  additional  share  of  vision. 

5.  The  age  affects  materially  the  consistence  of  the  lens,  whether 
in  health  or  disease.  Fluid  in  childhood,  gelatinous  in  youth,  firm 
at  middle  life,  hard  in  old  age,  the  lens,  affected  with  opacity,  may 
readily  be  divided  in  the  first  two  periods  by  the  needle,  and  will 
dissolve  in  the  aqueous  humour,  while  in  flie  last  two,  these  pro- 
cesses may  be  difficult  or  impracticable. 

6.  The  young  practitioner  ought  never  to  pronounce  absolutely 
even  on  the  existence  of  cataract,  without  dilating  the  pupil  by 
belladonna  ;  and  the  most  experienced  may  derive  advantage  from 
exposing  in  this  way  the  whole  field  of  the  disease  to  his  view. 

Proximate  Causes.  1.  The  most  frequent  kind  of  cataract  is 
that  which  occurs  in  old  age,  apparently  from  defective  nutrition 
of  the  lens,  and  independently  of  inflammation  or  injury.  We  as- 
cribe this  variety  of  cataract  to  a  gradual  decay  or  neci'osis  of  the 
lens.  The  process  begins  in  the  centre  of  that  body,  where  its  nu- 
trient vessels  are  smallest,  and  ends  in  its  complete  coagulation, 
death,  and  opacity.  It  also  loses  its  natural  adhesion  to  the  inter- 
nal surface  of  the  capsule,  and  in  some  cases,  an  effusion  of  fluid 
or  humor  Morgagni,  takes  place  between  the  capsule  and  the 
lens. 

2.  Next  in  point  of  frequency  is  cataract  from  injuries,  which, 
rupturing  the  capsule,  admit  the  aqueous  humour  into  contact  with 
the  lens.  In  four-and-twenty  hours  after  the  receipt  of  such  an  in- 
jury, we  sometimes  see  the  lens  rendered  opaque  by  the  coagulating 
influence  of  the  aqueous  humour.  Should  the  rupture  of  the  cap- 
sule remain  open,  the  whole  lens  may  dissolve  in  the  aqueous  hu- 
mour, be  absorbed  as  that  fluid  is  absorbed,  and  thus  the  pupil  clear, 
and  vision  be  restored.* 

But  if  the  wound  of  the  capsule  closes,  the  dissolution  ceases,  the 
cicatrice  of  the  capsule  assumes  a  chalk-white  appearance,  and  thus 
a  capsulo-lenticular  cataract  is  formed.  It  has  been  conjectured 
that  the  capsule  is  occasionally  ruptured  in  that  tetanic  state  of  the 
eyes  which  attends  the  convulsions  of  young  children,  so  that  the 
aqueous  humour  being  admitted  within  the  capsule,  the  lens  be- 
comes opaque.  In  some  cases,  a  blow  on  the  eye,  without  any 
penetration  of  its  tunics,  ruptures  the  capsule ;  in  others,  a  blow 

*  It  is  in  this  way  that  cataract,  originating  without  any  injury,  is  sometimes  cured 
by  a  blow  on  the  eye. 


478 

dislocates  the  capsule  with  the  lens  enclosed  in  it,  from  its  fosstila 
on  the  anterior  surface  of  the  vitreous  humour,  an  accident  which 
is  followed  by  coagulation  and  solution  of  the  contained  lens,  and 
thickening-  and  opacity  of  the  insulated  capsule ;  while  in  a  third 
set  of  cases,  cataract,  generally  attended  by  amaurosis,  follows  a 
blow,  without  any  apparent  rupture  or  dislocation. 

3.  Inflammation  is  in  some  cases  the  proximate  cause  of  cataract. 
Indeed,  anterior  and  posterior  capsular  cataracts  may  be  compared 
to  specks  of  the  cornea  ;  while  in  some  instances,  the  lens  also,  from 
long-continued  inflammation,  becomes  opaque,  dissolves  into  a  milky- 
like  fluid,  or  even  suppurates.  This  subject,  as  illustrated  by  the 
observations  of  Professor  Walther,  I  have  considered  in  the  twenty- 
fifth  section  of  Chapter  X.  Ossification  of  the  capsule  and  lens  is 
another  termination  of 'inflammation  in  these  parts,  which  has  al- 
ready been  spoken  of  at  page  432. 

4.  The  lens  is  gradually  changed  in  colour,  as  well  as  consist- 
ence, as  fife  advances.  Uniformly  gelatinous,  and  perfectly  colour- 
less and  transparent  at  puberty,  it  assumes  in  middle  life  a  yellow- 
ish hue  in  the  centre,  which  part,  at  the  same  time,  acquires  a  con- 
siderably greater  degree  of  tenacity  than  the  exterior  laminae  of  which 
the  lens  consists.  In  old  age,  the  lens  becomes  so  hard  throughout, 
that  it  can  never  easily,  and  often  cannot  at  all,  be  divided  by  the 
needle  introduced  into  the  eye,  while  at  the  same  time,  it  assumes 
a  deep  amber  colour,  sometimes  approaching  to  brown,  and,  as  we 
are  told,  even  to  black.  This  mere  depth  of  colour,  independent  of 
any  such  coagulation  as  occurs  in  the  common  cataract  of  old  peo- 
ple, is  sometimes  sufficient  to  impede  vision. 

Remote  and  Predisposing  Causes.  Many  of  these  have  hitherto 
escaped  detection  ;  but  the  following  have  been  ascertained  as  more 
or  less  frequent  in  their  operation. 

1.  Old  age. 

2.  Hereditary  tendency.  Instances  are  not  uncommon  of  this  dis- 
ease attacking  individuals,  one  of  whose  parents  had  been  affected 
with  it  about  the  same  period  of  life  ;  while  in  other  instances,  sev- 
eral brothers  or  sisters  are  either  congenitally  the  subjects  of  cataract, 
or  become  cataractous  in  after-life,  and  about  the  same  age. 

3.  Those  who  are  much  exposed  to  strong  fires,  as  glass-blowers, 
forgemen,  cooks,  (fee.  are  not  unfrequently  the  subjects  of  this 
disease. 

4.  The  use  of  wine  and  spiritoas  liquors,  but  especially  of  the 
former,  appears  to  favour  the  production  of  cataract,  which  is  a  com- 
mon disease  in  all  countries  where  wine  is  so  cheap  as  to  be  the 
habitual  beverage  of  the  lower  orders. 

5.  The  inhabitants  of  volcanic  countries,  as  Naples  and  Sicil)^, 
are  said  to  be  very  subject  to  cataract. 

6.  The  sudden  application  of  cold  to  the  extremities  of  the  body, 
so  as  to  check  any  natural  or  morbid  effort  or  evacuation,  such  as 
menstruation,  or  a  paroxysm  of  gout,  is  apt  to  be  succeeded  by 
cataract. 


479 

General  Prognosis.  The  prognosis  in  cases  of  cataract  must 
necessarily  vary  considerably  according  to  the  particular  species 
which  is  present,  the  local  complications  of  the  disease,  and  the  age 
and  general  health  of  the  patient. 

In  the  incipient  stage,  we  seldom  hesitate  in  prognosticating,  es- 
pecially if  the  lens  is  affected,  the  uninterrupted  increase  of  opacity, 
and  decrease  of  vision,  till  merely  a  perception  of  light  and  shadow 
be  retained.  Should  the  anterior  capsule  be  the  seat  of  partial  opa- 
city, this  may  remain  stationary  for  a  number  of  years,  or  through 
the  whole  of  life,  without  affecting  the  transparency  of  the  lens  ; 
but  posterior  capsular  cataract  rarely  continues  long  without  induc- 
ing lenticular  opacity. 

With  regard  to  the  ultimate  prognosis,  practitioners  are  too  much 
in  the  way  of  raising  sanguine  hopes  in  the  minds  of  patients  af- 
fected with  cataract,  that  by  surgical  operations  on  the  eyes,  their 
sight  may  be  almost  perfectly  restored  ;  not  weighing  with  sufficient 
consideration,  the  frequency  with  which  other  morbid  changes  in 
the  organ  of  vision  come  to  be  associated  with  this  disease,  especial- 
ly in  advanced  life ;  such  as  dissolution  of  the  vitreous  humour,  ab- 
sorption of  the  pigmentum  nigrum,  and  imperfect  sensibility  of  the 
retina.  Many  a  patient,  who,  before  the  operation,  discovers  the 
hand  passing  before  the  eye,  sees  very  little  more  after  the  opaque 
,lens  is  removed,  on  account  of  the  dulness  of  the  retina,  or  the  de- 
ficiency of  the  choroid  secretion. 

The  dangers,  too,  attending  the  operations  for  cataract,  are  much 
too  hghtly  estimated,  in  pronouncing  an  ultimate  prognosis  in  this 
disease.  Operators  on  the  eye  seem  to  think  that  they  have  done 
enough,  when  by  the  publigation  of  a  few  successful  cases,  they 
have  persuaded  the  profession  and  the  public  of  their  expertness : 
but  unless  the  circumstances  of  each  case  are  minutely  detailed,  and 
a  history  given,  not  of  select  cases,  but  of  every  case  occurring  dur- 
ing a  year,  or  longer  period,  and  each  history  brought  down,  not  to 
a  few  days  or  weeks  merely,  but  at  least  to  several  months,  no  con- 
clusion can  be  drawn,  regarding  either  the  abilities  of  the  operator, 
the  merits  of  his  particular  mode  of  operating,  or  the  general  success 
of  operations  for  the  cure  of  the  cataract.  Such  facts  only  as  the 
following  are  capable  of  serving  as  data  for  an  ultimate  prognosis  in 
cataract. 

1.  The  Royal  Academy  of  Surgery,  solicitous  to  know  the  truth 
with  respect  to  Daviel's  success,  applied  to  M.  Caque,  one  of  their 
correspondents,  who  resided  at  Rheims.  This  gentleman,  by  a 
letter  dated  15th  January,  1753,  informed  them,  that  Daviel  had 
there  operated  on  thirty-four  cases  ;  seventeen  of  which  were  per- 
fectly restored  to  sight,  eight  saw  indifferently,  and  nine  received 
no  benefit.* 

*  Memoires  de  I'Academie  Royale  de  Chirurgie,  12mo,  Tom.  v.  p.  397.    Paris. 

1787. 


480 

2.  In  June.  1753,  La  Faye,  Poyet,  and  Morand,  operated  the 
same  day  upon  nineteen  cataracts  ;  the  two  former  by  extraction, 
although  each  according  to  his  own  method ;  Morand.  by  depres- 
sion. Of  those  operated  on  by  La  Faye,  two  saw  well,  two  indif- 
ferently, and  two  received  no  benefit  at  all.  Two  of  Poyet's  cases 
saw  well,  two  less,  one  could  discover  only  day-light,  and  two  noth- 
ing. Three  of  Morand's  patients  could  see  tolerably  well,  and 
three  remained  as  dark  as  before.* 

3.  Mr.  Sharp,  in  a  paper  read  before  the  Royal  Society,  22d 
November,  1753,  gives  an  account  of  his  having  performed  the 
operation  of  extraction  on  nineteen  eyes,  with  about  half  of  which, 
he  had  what  he  thought  tolerable  success ;  though  he  grants  that 
not  a  single  one  escaped  a  considerable  degree  of  inflammation. t 

4.  Dr.  Tartra  has  published  the  results  of  the  operations  for  cat- 
aract, performed  in  the  Hotel-Dieu,  at  Paris,  from  the  commence- 
ment of  1806  to  1810,  inclusively.  The  total  number  of  cases  was 
113,  70  of  which  were  extracted,  and  43  displaced.  Nineteen  of 
the  70  extractions,  and  24  of  the  43  displacements,  were  successful ; 
6  extractions,  and  4  displacements,  were  followed  by  partial  suc- 
cess ;  8  extractions,  and  5  displacements,  were  total  failures  ;  and 
the  results  of  the  rest  were  either  unknown,  or  more  or  less  unfa- 
vourable. Dr.  T.  observes,  that  by  adding  to  the  43  successful 
cases,  the  other  10,  where  the  operation  was  attended  by  partial 
success,  it  appears  that  nearly  half  the  patients  operated  on,  obtained 
a  greater  or  less  degree  of  sight.  He  adds  that  it  is  generally 
thought  that  two  out  of  five  patients  operated  on  for  cataract,  re- 
cover their  sight. t 

Such  are  some  of  the  data,  furnished  to  us  from  the  practice  of 
general  surgeons,  on  which  to  found  an  ultimate  prognosis  with 
regard  to  cataract.  I  am  by  no  means  of  opinion,  that  the  prac- 
tice of  mere  oculists  would  aiford  more  favourable  results  ;  for  their 
ignorance  of  eye-diseases  being  in  general  fully  as  great  as  that  of 
general  practitioners,  they  are  led  to  operate  in  many  cases  where 
there  cannot  exist  the  slightest  rational  hope  of  success. 


SECTION   II. GENERA    AND  SPECIES  OF    CATARACT. 

The  most  important  classification  of  cataracts  is  that  which  ar- 
ranges them  into  true  and  spurious  ;  the  true  having  their  seat  in 
or  vnthin  the  crystalline  capsule,  and  the  sjntrious  without  / 
while  the  distinction  of  the  genera  and  species,  admitted  under 
each  of  these  classes,  is  founded  either  upon  the  particular  part  af- 
fected, or  particular  substance  forming  the  impediment  to  vision. 

True  cataract  frequently  exists  alone,  spurious  is  always  com- 
bined with  other  morbid  changes  in  the  eye. 

*  Ibidem,  Tom.  vi.  p.  332. 

t  Philosophical  Transactions  for  1753.  Vol.  xlviii.  Part  I.  p.  322.  London^, 
1754. 

t  De  rOperation  de  la  Cataracte,  p.  83.     Paris,  1812. 


481 

CLASS  I.— TRUE   CATARACTS. 

GENUS  I. LENTICULAR  CATARACT. 

Opacity  of  the  lens  is  the  most  frequent  kind  of  cataract.  Its 
colour  and  consistence  vary  according  to  the  period  of  life  at  which 
it  occurs.  In  old  persons,  in  whom  it  is  most  common,  the  opaci- 
ty is  generally  pretty  dark,  of  a  yellowish  or  amber-grey  colour ; 
in  younger  subjects,  it  is  often  of  the  hue  of  half-boiled  white  of 
egg  ;  in  children,  still  hghter,  and  approaching  more  to  the  colour 
of  milk  diluted  with  water.  The  opacity  commences  in  the  cen- 
tre of  the  lens,  and  spreads  to  its  surfaces  and  edge.  It  is  generally 
uniform  in  colour,  not  speckled,  but  fading  towards  the  edge  of  the 
lens.  In  some  cases,  it  presents  radii,  stretching  from  its  centre  to- 
wards its  circumference,  the  lens  already  tending  to  break  into 
such  divisions  as  we  see  it  fall  into,  when  left  to  putrify  or  undergo 
desiccation.  The  opaque  surface  of  the  lens  appears  plain,  or 
slightly  convex,  and  at  a  sufficient  distance  behind  the  pupil  to 
permit  a  shadow  to  be  cast  on  it  by  the  iris. 

This  cataract  has  in  general  no  influence  on  the  motions  of  the 
pupil,  being  scarcely  ever  so  large  as  to  press  against  the  iris,  and 
obhterate  the  posterior  chamber.  The  eyeball  is  in  general  healthy, 
except  in  old  people,  in  whom  this  disease  is  often  accompanied  by- 
dissolution  of  the  vitreous  humour,  and  deficiency  of  the  pigmen- 
tum  nigrum.  The  patient  is  seldom  totally  deprived  of  sight  by 
this  kind  of  cataract.  In  by  far  the  greater  number  of  cases,  he 
continues  to  distinguish  not  only  light  and  shadow,  but  even  bright 
colours ;  and  in  the  twilight,  when  the  pupil  expands,  he  often 
discovers  the  forms  of  large  objects,  especially  of  those  placed  to  one 
side.  On  entering  a  bright  light,  he  sees  none ;  and  in  some  rare 
cases,  the  opacity  is  so  dense  to  the  very  circumference  of  the  lens, 
that  not  even  light  and  shadow  are  distinguished. 

Lenticular  cataract  is  fluid  in  childhood ;  gelatinous  in  young 
persons ;  firm,  but  still  divisible  by  the  needle,  till  about  the  age  of 
45 ;  after  which,  and  especially  in  persons  of  60  and  upwards,  it 
is  so  hard  that  it  cannot  be  divided  by  the  needle. 

This  kind  of  cataract  is  the  most  favourable  for  operation,  and 
a  pure  case  of  this  sort,  with  a  lively  pupil,  ought  always  to  be 
selected  by  the  young  operator,  for  his  first  attempt. 

GENUS  II. CAPSULAR  CATARACT. 

Species  1.  Anterior  Capsular  Cataract. 
The  anterior  hemisphere  of  the  crystalline  capsule  is  much 
thicker,  and  more  consistent  than  the  posterior,  resembling  almost 
exactly  the  lining  membrane  of  the  cornea,  and  like  it,  rolling  it- 
self together  when  freed  from  its  natural  connexions.  It  is  much 
more  subject  to  opacity  than  the  posterior  capsule,  and  is  often 
opaque  when  the  posterior  is  transparent. 
61 


482 

The  opacity  in  anterior  capsular  cataract  is  nev^er  uniformly 
diffused  like  lenticular  opacity,  but  alvv^ays  streaked  or  speckled, 
and  is  generally  of  a  chalk  or  pearl  white  colour.  The  specks  are 
very  irregular  in  form  and  disposition  ;  some  of  them  stretching 
from  the  edge  of  the  capsule,  others  occupying  the  centre. 

The  quickness  of  the  motions  of  the  iris  is  in  general  diminished 
in  this  disease,  and  the  capsule  is  often  close  to  the  iris,  so  that  no 
shadow  is  thrown  upon  the  cataract. 

The  loss  of  sight  may  be  greater  or  less  than  in  lenticular  cata- 
ract, depending  partly  on  the  place  and  extent  of  the  specks,  partly 
on  coincident  changes  in  the  eye. 

As  we  have  reason  to  believe  that  this  disease  is  in  almost  all 
instances  the  result  of  inflammation,  we  might  expect  to  find  it 
frequently,  or  always,  conjoined  with  marks  of  iritis.  Yet  this  is 
rarely  the  case.  The  blood-vessels  which  nourish  the  anterior  cap- 
sule, are  derived  from  the  cihary  processes,  and  not  from  the  iris. 
Neither  are  they  the  chief  source  of  the  nutrition  of  the  lens. 
Hence  it  is,  that  anterior  capsular  cataract  is  really  seldom  com- 
bined with  morbid  changes  in  the  iris,  and  that  it  often  continues 
for  many  years,  or  for  hfe,  without  bringing  on  lenticular  opacity. 

Species  2,  Posterior  Cajjsular  Cataract 

Is  much  rarer  than  the  anterior,  and  as  the  blood-vessels  which 
nourisn  the  lens  are  chiefly  derived  from  the  posterior  capsule,  the 
present  disease  is  much  more  apt  to  superinduce  lenticular  opacity, 
so  that  the  ultimate  changes  of  ihe  posterior  capsule,  when  affected 
with  cataract,  come  to  be  hid  from  our  view. 

The  opacity  is  never  uniformly  diffused,  but  always  exhibits, the 
form  of  radiating  lines,  proceeding  from  the  centre  of  the  affected 
membrane.  The  ground  upon  which  these  opaque  lines  are  placed, 
is  evidently  concave,  while  the  lines  therpselves,  being  viewed 
through  the  crystalline  lens,  have  a  watery  dulness  of  appearance, 
easily  distinguishable  from  the  sharp  chalky  whiteness  of  the 
specks  in  anterior  capsular  cataract.  Occasionally  both  hemi- 
spheres of  the  capsule  are  the  seat  of  partial  opacity,  the  lens  re- 
maining transparent. 

Posterior  capsular  cataract  has  no  influence  on  the  iris,  unless  it 
is,  as  I  have  once  or  twice  observed  it,  combined  with  amaurosis. 
I  have  repeatedly  witnessed  this  disease  without  any  complication 
whatever. 

Vision  is  impaired  by  this  cataract  in  very  various  degrees,  the 
patient  being  able,  in  some  cases,  to  read  with  the  aid  of  a  mag- 
nifying glass ;  while  in  other  instances,  he  is  almost  totally  de- 
prived of  sight. 

This  disease  is  sometimes  slow,  and  continues  for  years  in  the 
same  state.  In  an  instance  which  came  under  ray  observation, 
it  occurred  suddenly  in  both  eyes,  in  consequence  of  stoppage  of  the 
menses  from  cold,  and  was  speedily  followed  by  lenticular  opacity. 
So  long  as  the  lens  continues  transparent,  this  cataract  is  not  to  be 


483 

I  touched  in  the  way  of  operation.  Even  after  the  lens  does  become 
lopaqiie,  the  case  is  but  an  unfavourable  one,  owing  to  the  difficulty 
I  of  removing  the  posterior  capsule. 

GENUS  III. MORGAGNIAN  CATARACT. 

The  efifusion  of  an  opaque  fluid  between  the  lens  and  its  capsule^ 
Iforms  one  of  the  rarest  kinds  of  cataract.     It  is  generally  followed, 
after  a  time,  by  disorganization  and  dissolution    of  the  lens,  and 
not  unfrequently  by  capsular  opacity. 

This  cataract,  so  long  as  it  consists  "in  a  mere  effusion  between 
the  capsule  and  lens,  presents  a  cloudy  appearance,  as  if  formed  of 
milk  and  water  imperfectly  mixed.  If  the  eyeball  is  repeatedly 
[rubbed  with  the  finger,  through  the  medium  of  the  eyelids,  the 
clouds  of  opacity  change  their  outline  and  position  ;  and  sometimes 
they  do  so,  merely  on  quick  motion  of  the  eye  from  side  to  side. 

The  capsule  is  distended  in  cases  of  Morgagnian  cataract,  and 
pressing  against  the  iris,  obliterates  the  posterior  chamber,  and  im- 
pedes the  motions  of  the  pupil. 

Vision  is  sometimes  but  slightly  impaired,  so  long  as  the  disease 

is  purely  Morgagnian,  small  objects  only  escaping  the  observation 

of  the  patient,  especially  after  the  eye  has  been  rubbed  or  moved  ;  but 

!  after  the  lens  dissolves,  the  sight  is  limited  to  the  perception  of  light 

iand  shadow. 

Beer  observes,  that  this  disease  is  sudden  in  its  accession.     The 
I  only  cause  he  had  known  to  operate  apparently  in  its  production, 
was  exposure  of  the  eyes  to  the  evaporation  of  mineral  acids,  during 
I  the  oxidation  of  metals. 

It  is  not  to  be  touched  in  the  way  of  operation  ;  and  ma}''  perhaps 
be  curable  by  other  means,  if  attended  to  sufficiently  early. 

GENUS  IV. CAPSULO-LENTICULAR    CATARACT. 

This  is  a  union  of  the  first  two,  or  even  of  the  three  ^Tcnera 
already  described.  The  appearances,  and  even  more  eeseiitinl  cir- 
cumstances in  capsulo-lenticulav  cataract,  are  so  unlike  in  different 
cases,  that  it  is  necessary  to  distinguish  several  species  of  I  his  genus. 
The  circumstances  in  question,  influence  the  choice  and  manner 
of  operation. 

iSpecies  1.     Central  Cajisido-lenticidar  Cataract 

Presents  in  general  a  very  limited  white  point  in  the  centre  of 
the  lens  and  anterior  capsule,  occasionally  remaining  unchanged 
through  life.  It  is  not  very  unfrequent  in  children,  vvboni  it  ren- 
ders short-sighted,  so  that  they  cannot  read  or  write.  In  some 
instances,  the  lenticular  opacity  is  considerably  broader  than  the 
capsular,  and  not  so  opaque. 

This  disease  is  probably  congenital.  In  one  case  which  fell 
under  my  observation,  it  was  not  observed  till  after  scarlet  fever, 
and  was  supposed   to  have  originated  in  that  complaint. 

When  very  small,  it  is  not  to  be  touched  in  the  way  of  operation. 


484 


Species  2.     Common  Capsulo-lenticular  Cataract 

Is  by  no  means  rare.  It  may  originate  in  the  capsule  in  the 
lens,  or  in  a  Morgagnian  effusion.  Injury  of  the  capsule  and  lens 
may  give  rise  to  this  kind  of  cataract,  but  its  most  frequent  cause 
is  probably  an  insidious  inflammation  of  the  capsule. 

The  opacity  is  partly  chalky  or  pearly,  as  in  anterior  capsular 
cataract;  partly  cloudy,  as  the  Morgagnian.  The  specks  of  the  cap- 
sule have  innumerable  forms,  and  on  these  were  founded  the  old 
distinctions  of  cat ar acta  marmoracea,fenestrata^  stellata.,  punc- 
tata,  dimidiata,  <^c. 

In  some  cases,  the  opacity  of  the  lens  and  capsule  is  only  partial, 
so  that  on  dilating  the  pupil  by  belladonna,  the  patient's  vision  is 
considerably  improved.  The  lens  presents  various  degrees  of  con- 
sistence in  capsulo4enticular  cataract;  being  sometimes  hard;  in 
other  cases,  partially  or  completely  dissolved  into  a  thick  milk-like 
fluid.  In  the  latter  state,  it  sometimes  distends  the  capsule  so  much, 
that  the  posterior  chamber  is  obliterated,  and  the  iris  prevented 
from  moving  with  facility.  Belladonna  dilates  the  pupil  slowly 
and  still  more  slowly  does  it  return  to  its  former  size.  It  is  some- 
times the  case,  that  even  the  anterior  chamber  is  diminished  by 
the  pressure  of  the  distended  capsule,  and  the  consequent  advance- 
ment of  the  iris. 

Sensibility  to  light  is  occasionally  very  feeble  in  this  state  of 
the  lens  and  capsule.  In  some  cases,  however,  it  is  observed,  that 
if  the  patient  remains  perfectly  at  rest,  and  in  the  sitting  position, 
for  a  quarter  of  an  hour,  the  whiter  and  thicker  part  of  the  dissolved 
lens  falls  to  the  bottom  of  the  cavity  of  the  capsule,  and  the  anterior 
hemisphere  of  the  capsule  not  being  altogether  opaque,  but  merely 
speckled,  vision  becomes  clearer,  from  the  light  being  belter  trans- 
mitted through  the  upper  half  of  the  cataract ;  but  on  motion  of 
the  eye,  the  contents  of  the  capsule  are  again  mingled  together, 
and  the  vision  becomes  as  obscure  as  before. 

A  still  more  remarkable  improvement  in  vision  occasionally 
takes  place  in  cases  of  capsulo-lenticular  cataract,  with  dissolved 
lens,  after  the  capsule  is  simply  punctured  with  the  cataract-needle, 
so  as  to  allow  the  opaque  fluid  contained  within  the  capsule  to  es- 
cape. This  fluid  is  speedily  absorbed,  and  the  hght  transmitted 
through  the  transparent  portions  of  the  cataracta.  fenestrata 
which  remains,  is  sometimes  sufficient  for  a  considerable  share  of 
vision. 

Congenital  cataract  is  generally  found  to  be  capsulo-lenticular, 
the  lens  being  milky,  and  the  anterior  capsule  of  a  bluish-white 
colour.  In  a  case  of  congenital  cataract,  upon  which  I  lately  ope- 
rated, I  found  the  one  cataract  such  as  I  have  now  described,  but 
in  the  other  eye,  the  lens  was  fluid,  and  of  a  white  colour,  without 
any  opacity  of  the  capsule.  The  patient  was  a  boy  of  about  five 
years  of  age.     In  a  girl  of  eighteen,  affected  with  congenital  cata- 


I  485 

ract,  on  whom  I  operated  some  time  previously,  I  found  merely  a 
scale  of  chalky  lens,  enclosed  in  an  opaque  capsule,  an  approach  to 
what  is  termed  the  siliquose  cataract. 

Species  3.  Cystic  Capsiilo-lenticular  Cataract 

Is  always,  or  almost  always,  the  result  of  a  blow  either  on  the 
eye  or  the  edge  of  the  orbit,  more  frequently  on  the  latter,  suffi- 
ciently violent  to  separate,  by  its  concussion,  the  lens  enclosed  in 
its  capsule,  from  the  vitreous  humour.  In  consequence  of  such 
an  accident,  the  capsule  and  lens  become  opaque,  and  the  lens  dis- 
solves. 

'  The  opacity  is  white,  and  nearly  uniform  ;  the  opaque  body  is 
very  convex,  and  pushes  itself  against  the  circumference  of  the  pu- 
pil. After  a  time,  the  aqueous  humour  of  the  posterior  chamber 
appears  to  become  unnaturally  abundant,  so  that  the  cataract  bobbs 
about  in  it  on  ev^ery  motion  of  the  head.*  Like  a  lens  bursting  the 
capsule  from  a  blow,  and  passing  into  the  anterior  chamber,  the 
cystic  cataract  sometimes  rolls  forward  through  the  pupil,  and  rest- 
ing between  the  cornea  and  iris,  induces  inflammation  of  the  lat- 
ter. 

Cystic  cataract  is  rarely,  if  ever,  unattended  by  amaurosis,  so 
that  if  extraction  is  had  recourse  to,  it  is  not  so  much  with  any  hope 
of  restoring  vision,  as  merely  to  free  the  patient  from  the  pain 
which  is  certain  of  being  excited,  if  the  cataract  comes  forward  into 
the  anterior  chamber,  and  the  danger  of  sympathetic  inflammation 
attacking  the  other  eye.  On  extraction,  the  opaque  capsule  is 
sometimes  found  greatly  thickened. 

Species  4.    Siliquose  Capsulo-lenticular  Cataract 

lb  occasionally  met  with  in  adults,  but  more  frequently  in  chil- 
dren. Its  origin  in  the  former  is  ascertained  ;  in  the  latter  it  is  a 
matter  of  conjecture.  In  both,  the  chief  characteristics  of  the  dis- 
ease are  interrupted  reproduction,  and  even  diminution  or  entire 
absorption,  of  the  lens,  with  a  shrunk  and  wrinkled  capsule.  In 
the  adult,  a  mere  scale  of  lens  is  all  that  remains,  surrounded  by  a 
shrivelled  capsule,  which  is  hence  compared  to  a  large  withered 
husk  surrounding  a  shrunk  seed.  In  the  young  subject,  the  lens 
is  not  unfrequently  com|)letely  gone,  and  the  two  hemispheres  of 
the  capsule  in  contact,  so  as  to  form  an  opaque,  and  elastic  double 
membrane. 

In  adults,  this  disease  is  generally  the  result  of  a  penetrating 
wound  of  the  capsule,  through  which  the  aqueous  humour  having 
been  admitted,  the  exterior  and  softer  parts  of  the  lens  have  been 
dissolved,  and  the  nucleus  left. 

Schmidt  had  observed  this  kind  of  cataract  onl)^  in  young  per- 
sons, who,  during  childhood,  had  been  affected  with  convulsions, 

*  Cataracts,  tremulans  vel  natatilis ;  Cataracte  branlante. 


486 

during  which  he  supposed  rupture  of  the  capsule  to  have  happened, 
and  thus  the  aqueous  humour  to  have  been  adrnitLed  to  the  l(3ns. 
Beer,  however,  rnet  with  tliis  disease  in  children  scarcely  two  mouths 
old,  in  whom  no  convulsions  had  ever  happened. 

Whether  it  is  possible  for  the  lens  to  be  absorbed,  without  the 
agency  of  the  aqueous  hmnour,  leaving  the  capsule  shrunk,  but 
entire,  is  a  point  yet  undetermined. 

The  opacity  of  a  siliquose  cataract  in  children,  is  generally  of  a 
light  gray  colour,  rarely  very  white.  The  capsule  is  evidently  cor- 
rugated ;  the  cataract  of  small  volume,  and  at  a  considerable  dis- 
tance behind  the  iris.  In  adults,  again,  this  cataract  is  often  very 
white,  especially  at  any  spot  where  the  capsule  has  suffered  from 
injury  ;  elsewhere,  it  is  dusky,  or  yellowish.  It  does  not  advance 
in  a  convex  form,  but  appears  flat. 

Neither  in  children,  nor  in  adults,  is  the  iris  affected  in  its  mo- 
tions, unless  it  is  adherent  to  the  capsule  from  inflammation. 

Yision  is  sometimes  completely  lost,  from  the  efl'ects  of  the  origi- 
nal cause  on  the  retina ;  in  other  cases,  distinct  sensibiUty  to  light 
is  retained,  so  that  an  operation  may  be  had  recourse  to  with  a  rea- 
sonable hope  of  success. 

Species  5.     Bursal  Capsulo-lenticidar  Cataract. 

One  of  the  rarest  kinds  of  cataract  consists  in  capsulo-lenticular 
opacity,  combined  with  the  presence,  within  the  capsule,  of  a  small 
cyst,  filled  with  purulent  matter.  This  cyst  has  geneially  been 
found  behind  the  lens,  but  occasionally  before  it. 

The  opacity  is  orange  ;  the  iris  sluggish  ;  the  posterior  chamber 
obliterated  by  the  pressure  of  the  over-distended  capsule ;  the  per- 
ception of  light  indistinct ;  the  whole  habit  weakly  and  cachectic. 

CLASS  II.— SPURIOUS  CATARACTS. 

GENUS   1.  — FIBRINOUS    CATARACT. 

An  effusion  of  fibiin,  or  coagulable  lymph,  in  consequence  of  in- 
flammation of  the  iris  and  capsule,  constitutes  by  far  the  most 
frequent  kind  of  spurious  cataract.  It  is  in  almost  all  cases  at- 
tended by  opacity  of  the  anterior  hemisphere  of  the  capsule,  and 
occasionnlly  by  capsulo-lenticular  cataract.  The  effused  lymph  is 
met  with  in  different  states,  and  hence  the  distinctions  which  fol- 
low. 

Species  1.  Flocciilent  FihriJious  Cataract. 

In  this,  as  in  all  the  fibrinous  cataracts,  the  patient  furnishes  the 
first  step  10  a  knowledge  of  the  nature  of  the  case,  by  at  once  an- 
nouncing to  us,  that  his  bhndness  was  preceded  by  a  painful  and 
tedious  inflammation  of  the  eye. 

The  opacity  w  hich  is  visible  behind  or  within  the  pupil,  is  in  the 
form  of  a  fine  net-work,  surrounded  by  a  misshapen,  contracted, 
and  partially  or  completely  adherent  pupil. 


487 

Vision  is  much  impaired,  although  not  always  in  proportion  to 
the  queintity  of  effused  lymph  ;  for  sometimes  when  the  pupil  is 
small,  and  the  spurious  cataract  considerable,  a  tolerable  degree  of 
sight  is  retained  ;  while  in  other  cases,  although  the  pupil  is  large, 
and  the  net-work  of  lymph  thin,  the  patient  is  almost  totally  blind, 
the  inflammation  in  which  these  morbid  changes  had  originated 
having  probably  extended  its  influence  to  the  retina. 

Species  2.   Clotted  Fibrinous  Cataract. 

In  this  case,  a  clot  of  lymph,  apparently  unorganized,  occupies 
the  pupil,  and  sometimes  even  projects  through  it.*  The  opacity 
is  white  ;  the  pupil  angular,  and  motionless  ;  sensibility  to  light 
indistinct,  or  wanting.  In  most  cases,  the  lymph  is  adherent  to 
the  capsule,  which  is  also  opaque  and  thickened  ;  but  occasionally, 
the  lymph  is  unadherent,  and  the  capsule  tolerably  clear. 

Species  3.   Trabecular  Fibrinous  Cataract  A 

The  pupil,  in  this  species  also,  is  angular  and  narrowed,  and 
behind  it,  lies  a  capsu'o-lenticular  cataract,  in  front  of  v.'hich  there 
is  a  stripe,  or  bar  of  lymph,  running  sometimes  in  one  direction, 
sometimes  in  another.  This  substance  is  connected  at  each  side 
with  the  edge  of  the  pupil,  but  it  does  not  cease  there.  Passing 
behind  the  iris,  it  attaches  itself  to  that  membrane,  or  to  the  ciliary 
processes.  The  bar  varies  in  consistence,  being  sometimes  car- 
tilaginous, or  even  osseous. 

The  iris  is  motionless  ;  the  perception  of  light  extremely  indis- 
tinct, or  wanting ;  and  the  eyeball  not  unfrequently  atrophic. 

GENUS  II. PURULENT  CATARACT 

Is  much  less  frequent  than  the  fibrinous.  In  cases  of  neglected 
hypopium,  the  matter  is  after  a  time  absorbed,  and  the  pupil  again 
brought  into  view.  It  is  observed,  however,  to  be  occupied  by  a 
spurious  cataract,  of  a  yellowish  colour,  which  is  nothing  more  than 
particles  of  purulent  matter,  involved  in  the  interstices  of  a  web  of 
fibrin.  Vision,  under  such  circumstances,  is  in  general  irretrieva- 
bly lost. 

GENUS  III. SANGUINEOUS    CATARACT, 

Like  the  last  mentioned,  has  its  basis  in  a  fibrinous  effusion,  in 
the  interstices  of  which,  minute  clots  of  red  blood  are  observed  (o 
lodge,  some  of  the  blood-vessels  of  the  iris  or  choroid  having  been 
ruptured  by  some  previous  injury,  or  during  severe  inflammation. 

Tlie  iris  is  not  so  much  contracted  in  this  as  in  some  of  the 
former  cases  of  spurious  cataract,  unless  hypopium  also  has  been 
present. 

"  Cataracta  pyramidata.  t  Cataracta  barree 


488 


GENrs    IV. PIGMENTOUS    CATARACT 

Consists  in  a  quantity  of  pigmentum  nigrum,  derived  from  the 
posterior  surface  of  the  iris,  and  adhering  to  the  capsule.  In  some 
cases,  this  spurious  cataract  is  the  result  of  iritis,  during  the  course 
of  which,  belladonna  having  been  applied,  while  other  remedies 
were  probably  neglected,  the  proper  substance  of  the  iris  was  forced 
to  contract,  leaving  the  pigmentum  nigrum,  or  uvea,  bound  to  the 
capsule  by  effused  lymph.  In  other  cases,  a  blow  on  the  eye  has 
the  effect  of  detaching  a  quantity  of  pigmentum  nigrum  from  the 
iris.  Falling  upon  the  capsule,  it  there  adheres,  and  the  capsule 
afterwards  beconjing  opaque,  probably  from  the  same  cause  v.hich 
detached  the  pigmentum  nigrum,  this  substance  forms  a  striking 
contrast  with  the  white  ground  upon  which  it  is  placed.  In  either 
of  these  sets  of  cases,  the  flakes  of  black  pigment  present  somewhat 
of  a  leafy  appearance,  and  hence  the  name  cataracta  arborescens, 
which  Ricliter  bestowed  on  this  sort  of  spurious  cataract. 

The  degree  of  vision  is  generally  very  hmited,  whether  iritis  or 
injury  of  the  eye  has  been  the  cause. 


SECTIOX     III. VARIOUS      ADDITIONAL     CLASSIFICATIONS     AND 

DISTINCTIONS  OF  CATARACT. 

Cataracts  are  often  classified,  or  at  least  distinguished,  according 
to  their  consistence,  size,  colour,  duration,  and  curabihty.  Those 
who  have  carefully  studied  the  classification  of  cataracts  founded  on 
the  part  or  parts  affected  in  each  genus,  can  be  at  little  loss  in  re- 
gard to  these  additional  circumstances,  which  may  therefore  be  dis- 
missed in  a  few  words. 

1.   Consistence. 

1.  Hard.  Only  a  lenticular  cataract  can  be  hard,  but  all  lenticu- 
lar cataracts  are  not  possessed  of  this  property,  not  even  when  they 
occur  in  persons  far  advanced  in  life.  Yery  rarely  do  we  meet  with 
hard  cataract  in  those  under  forty-five  years  of  age.  In  an  old 
person,  the  darker  the  gray  or  arnber  colour,  and  the  smaller  a  len- 
ticular cataract  is,  the  harder  it  will  be  found.  A  hard  lens  is  nev- 
er white,  and  never  so  large  as  to  prevent  a  shadow  from  being 
thrown  on  it  by  the  iris. 

2.  Tough.  This  is  a  property  which  resides  either  in  the  cap- 
sule, or  in  some  substance  effused  into  the  posterior  chamber.  The 
cystic,  siliquose,  and  trabecular  cataracts  are  of  this  description. 
They  are  all  more  or  less  white. 

3.  S'oft.  This  is  a  property  which  resides  in  the  lens.  In  sub- 
jects about  twcnl3'-five,  we  find  lenticular  cataract  soft  and  cohesi^'e, 
so  that  although  the  needle  passes  freely  through  its  substance,  the 
fragments  do  not  readily  separate,  at  least  on  a  first  operation. 
After  the  aqueous  humour  is  admitted  into  contact  with  such  a  cat- 


489 

aract,  it  becomes  more  friable.  The  colour  of  a  soft  cataract,  is  a 
light-gray,  or  grayish-white.  Not  unfrequently,  the  soft  lenticular 
cataract  is  stellated  from  the  division  of  the  lens  into  triangular  por- 
tions. During  extraction,  such  a  cataract  is  extremely  apt  to  fall 
into  pieces. 

4.  Fluid.  The  capsule  is  generally  opaque,  when  it  contains  a 
fluid,  or  dissolved  lens.  In  some  cases,  the  opacity  and  fluidity  of 
the  lens  precede  the  opacity  of  the  capsule  ;  while  in  other  cases, 
the  opacity  of  the  capsule  appears  to  operate  as  a  cause  of  the 
disorganization  of  the  lens.  The  latter  appears  to  be  the  fact  in 
ordinary  cases  of  capsulo-lenticular  cataract ;  while  in  congenital 
cases,  the  opacity  of  the  capsule  is  certainly  preceded  by  that  of  the 
lens.  Fluid  cataract  is  always  white.  In  some  cases,  the  heavier 
part  of  the  dissolved  lens  may  be  seen  to  gravitate,  on  rest  of  the 
patient's  head,  to  the  lower  part  of  the  capsule.  Leaning  the  head 
forwards  or  backwards,  also  affects,  in  some  instances,  the  position 
of  a  fluid  cataract. 

5.  Mixed.  The  Morgagnian  is  an  example  of  a  mixed  cata- 
ract ;  the  capsule  being  tough,  the  lens  hard  or  soft,  according  to  the 
age  of  the  patient,  and  the  Morgagnian  effusion  fluid.  The  bursal 
cataract,  and  capsulo-lenticular  cataracts  in  general,  are  also  mixed. 

These  distinctions,  founded  on  the  consistence  of  cataracts,  are 
important,  chiefly  in  reference  to  the  cure  of  this  disease  by  the 
operations  of  division  and  extraction. 

II.  Size. 

The  hard  lenticular  cataract  is  small,  as  is  also  the  siliquose  cat- 
aract ;  the  soft,  fluid,  and  mixed  cataracts,  are  large.  The  size  is 
estimated  by  the  presence  or  absence  of  aqueous  humour  in  the 
posterior  chamber,  as  indicated  by  the  breadth  of  shadow  thrown  on 
the  cataract  by  the  iris,  or  the  absence  of  such  shadow. 

III.  Colour. 

The  lens,  when  affected  with  cataract,  forms  a  bluish-white, 
light-gray,  amber,  or  brown  opacity,  according  to  the  age  of  the 
patient,  and  the  nature  of  the  disease.  Green  cataract  is  a  compli- 
cation of  lenticular  cataract  with  glaucoma.  The  bursal  cataract 
is  orange.     Capsular  cataract  is  always  white  or  pearly. 

IV.  Duration  and  development. 

In  former  times,  the  distinction  of  ripe  and  unripe  cataracts  was 
considered  of  great  importance.  It  was  supposed  that  cataract  de- 
pended on  the  coagulation  of  a  fluid ;  and  till  this  process  was 
judged  to  be  sufficiently  advanced  to  permit  of  the  cataract  being 
displaced  by  the  needle,  the  disease  was  deemed  unripe.*     If  we 

*  Expectandum  igitur  est  donee  jam  non  fluere,  sed  duritie  quidam  concrevisse 
videatur.     Celsus  de  Re  Medica,  Lib.  VII.  Pars.  II.  Cap.  I.  Sect.  ii. 

62 


490 

are  still  to  retain  the  terms  ripe  and  unripe,  we  must  employ  them 
with  a  very  different  meaning.  However  small  or  soft  a  cataract 
may  be,  we  may  call  it  ripe,  when  it  is  completely  developed,  and 
susceptible  of  no  farther  progress ;  whereas,  we  may  call  it  unripe, 
when  it  is  not  yet  fully  formed,  and  when  there  is  a  suspicion  that 
the  opacity  will  make  considerable  farther  progress,  as  is  the  case 
with  the  central  cataract,  and  the  posterior  capsular.  These  may 
continue  for  years  unripe  for  operation. 

The  distinctions  of  sudden  and  slow  cataracts,  and  of  those 
which  exist  from  birth,  or  supervene  at  various  periods  of  life,  are 
not  undeserving  of  attention.  It  must  be  observed,  however,  that 
congenital  cataract  is  not  always  of  the  same  sort,  but  may  be  cap- 
sular, lenticular,  or  capsulo-lenticular ;  and  hence  the  impropriety 
of  using  the  phrase  congenital  cataract^  as  if  it  were  significant 
of  any  thing  more  than  the  date  of  the  disease. 

V.  Curability. 

Pellier  introduced  a  practical  or  empirical  distinction  of  three 
principal  varieties  of  cataract ;  namely,  the  true,  or  curable ;  the 
mixed,  or  doubtful ;  and  the  false,  or  incurable.  The  true,  or 
curable,  was  to  be  known  by  the  pupil  retaining  its  natural  power 
of  contracting  and  dilating  in  full  perfection,  while  the  patient  was 
at  the  same  time  able  to  distinguish  the  light  of  a  candle,  or  of  any 
other  luminous  body,  and  even  certain  bright  colours,  such  as  red, 
green,  &c.  The  mixed,  or  doubtful,  was  characterised  by  a  feeble 
contraction  and  dilatation  of  the  pupil,  and  the  patient  could  scarcely 
distinguish  light  from  darkness.  Along  with  an  opaque  state  of 
the  lens,  this  variety  was  supposed  to  be  attended  with  disease  of 
the  retina,  or  of  some  other  part  of  the  eye.  In  the  false,  or  in- 
curable cases,  along  with  an  opaque  state  of  the  lens,  there  was 
either  a  dilated  or  a  contracted  state  of  the  pupil,  the  iris  remaining 
immovable,  to  whatever  degree  of  light  the  eyes  might  be  ex- 
posed, and  the  patient  unable  to  distinguish  between  the  most  bril- 
liant light  and  perfect  darkness.* 


SECTION  IV. COMPLICATIONS  OP  CATARACT. 

Cataract  frequently  presents  itself  along  with  other  diseases  of 
the  eye,  either  purely  local,  or  of  constitutional  origin ;  while  in 
other  cases,  it  is  complicated  with  constitutional  diseases,  which 
may,  or  may  not  have  been  instrumental  in  producing  the  cataract 
itself.  A  perfectly  uncomplicated  case  is  very  rarely  met  with.  It 
must  evidently  be  a  question  of  the  highest  importance  in  every 
instance  of  this  disease.  Is  the  organ  of  vision  in  a  condition  to  re- 
sume its  office  to  any  useful  extent,  were  the  cataract  removed  1 

*  Cours  d'Operations  sur  la  Chirurgie  des  Yeux.     Tome  I.  p.  172.    Paris,  1789, 


491 

1.  As  for  purely  local  complications,  I  may  mention  those  with 
inflammation  and  its  consequences,  such  as  specks  of  the  cornea, 
adhesion  between  the  iris  and  the  cornea,  or  between  the  iiis  and 
the  capsule.  Such  complications  as  these  will  readily  be  recog- 
nized, and  will  influence  us  in  the  choice  of  an  operation,  and  in 
the  mode  of  executing  the  particular  operation  which  we  may  select. 

2.  Some  other  local  complications  cannot  easily,  if  at  all,  be  dis- 
covered, except  at  the  moment  of  operation ;  such  as  preternatural 
adhesion  between  the  capsule  and  the  lens,  sometimes  sufficient  to 
prevent  extraction  from  being-  accomplished,  and  a  dissolved  state 
of  the  vitreous  humour,  a  complication  scarcely  less  perplexing. 
The  latter  is  a  frequent,  if  not  a  constant  attendant  on  glaucoma, 
and  if  the  patient  is  known  to  have  been  glaucomatous  before  be- 
coming the  subject  of  cataract,  we  must  be  on  our  guard  against  a 
fluid  vitreous  humour ;  but  in  many  instances,  nothing  is  known 
regarding  the  previous  state  of  the  eye,  and  there  is  no  very  mani- 
fest sign  to  lead  us  to  a  knowledge  of  the  fact. 

3.  Such  complications  as  the  following  are  very  unfavourable, 
yet  not  sufficiently  so,  as  absolutely  to  prevent  us  from  operating  ^ 
myosis  or  contracted  pupil,  not  arising  from  inflammation,  tremu- 
lous iris,  slight  varicosity,  slight  bogginess,  preternatural  firmness 
of  the  eyeball.  In  all  of  these  cases,  we  may  suspect  an  imperfect 
sensibility  of  the  retina,  and  that  although  the  patient  may  recover 
a  certain  share  of  vision  by  the  removal  of  the  cataract,  the  im- 
provement will  be  but  very  limited  and  temporary. 

4.  If  the  pupil  is  much  dilated  and  fixed,  and  the  patient  unable 
to  distinguish  day  from  night,  there  can  be  no  doubt  that  such  a 
degree  of  amaurosis  is  present  as  renders  it  quite  needless  to  think 
of  an  operation.  But  we  would  not  willingly  operate,  even  in  cases 
where  a  much  less  considerable  degree  of  amaurosis  was  present, 
were  we  aware  of  the  fact.  The  mere  perception  of  the  hand  pass- 
ing between  the  light  and  the  eye,  is  by  no  means  a  sufficient  in- 
dex that  the  retina  is  free  from  amaurosis.  The  amaurosis,  indeed, 
must  be  in  the  incompieie  stage,  if  so  much  sensibility  is  retained ; 
but  if  from  the  history  of  the  case,  and  the  appearances  of  the  eye, 
there  is  reason  to  dread  that  the  retina  retains  meiely  the  power  of 
distinguishing  light  and  shadow,  as  it  often  does  in  incomplete  am- 
aurosis, it  would  be  much  better  to  let  the  patient  alone,  than  to  be 
raising  in  his  mind  false  hopes  of  restoration  to  sight,  subjecting 
him  to  the  anxieties  attendant  on  an  operation,  and  exposing  him 
to  the  troubles,  often  severe  and  long  continued,  which  are  apt  to 
follow.  For  instance,  if  a  patient,  far  advanced  in  life,  discerns 
merely  light  and  shadow,  and  does  not  possess  the  natural  degree 
of  control  over  the  muscles  of  the  eyes,  so  that  on  being  desired  to 
look  in  any  particular  direction,  he  gazes  in  that  direction  with  a 
movement  of  the  whole  head,  but  without  any  movement  of  the 
eyes,  it  is  almost  useless  to  operate. 

5.  I  have  sometimes  operated  for  cataract  on   an  eye  affected 


492 

with  strabismus ;  but  even  when  I  have  done  this  in  children,  in 
the  expectation  that  the  accession  of  vision  consequent  to  the  re- 
moval of  the  cataract  would  operate  in  curing  the  squint,  I  have 
been  disappointed. 

6.  Fully  developed  glaucoma  with  cataract  is  readily  recognized. 
The  opacity  is  greenish,  or  even  sea-green.  The  cataract  is  volu- 
minous, and  seems  still  more  so  than  it  really  is,  from  being  pressed 
forwards  by  the  diseased  and  superabundant  vitreous  humour.  At 
last,  the  lens  is  pushed  in  some  degixe  even  through  the  pupil. 
The  iris  is  discoloured  ;  the  pupil  dilated,  and  completely  motion- 
less. The  pupil  is  generally  dilated  irregularly,  the  iris  shrinking 
chiefly  in  one  or  two  directions,  so  that  the  pupil  becomes  oblong 
or  angular.  The  edge  of  the  pupil  appears  to  be  rolled  back  into 
the  posterior  chamber.  The  eyeball  feels  as  hard  as  a  pebble.  Its 
external  blood-vessels,  and  often  the  internal  ones  also,  are  varicose. 
Internal  flashes  of  light  are  frequently  experienced  by  the  patient, 
who  is  totally  deprived  of  any  power  of  perceiving  light  from  with- 
out. Arthritic  ophthalmia,  with  severe  and  long-continued  head- 
ach,  is  generally  the  precursor  of  this  hopeless  condition  of  the  eye. 

7.  As  for  general  and  remote  complications  of  cataract,  the  va- 
riety is  endless.  Among  the  most  frequent  are  rheumatism,  scrof- 
ula, gout,  and  syphilis,  as  general,  and  inveterate  ulcers  on  the 
lower  extremities,  as  remote  complications.  It  is  highly  in^portant 
to  make  ourselves  acquainted  with  the  existence  of  any  such  com- 
phcations,  and  with  the  complete  history  of  the  patient's  health 
who  consults  us  on  account  of  cataract.  For  instance,  if  an  indi- 
vidual labouring  under  this  disease,  be  of  an  inflammatory  tendency, 
great  care  will  be  required,  both  before  and  after  an  operation,  to 
avoid  the  causes  of  plethora  and  arterial  action.  It  will  probably 
be  only  by  repeated  blood-letting  and  purging,  with  an  abstemious 
diet,  both  before  and  after  removing  the  cataract,  that  the  eye  will 
escape  destructive  inflammation. 


SECTION  v. TREATMENT  OF  CATARACT   WITHOUT  OPERATION. 

Three  different  modes  of  treating  cataract  without  operation,  have 
occasionally  been  had  recourse  to  ;  viz.  the  antipldogistic,  the 
stimulant,  and  the  counter-irritant.  It  may  fairly  be  questioned, 
whether  such  means  have  ever  succeeded  in  any  case  of  true  cata- 
ract, in  restoring  the  natural  transparency  of  the  parts.  Most  of 
the  alleged  cures  have,  in  all  probability,  been  either  instances  of 
mere  fibrinous  effusions  on  the  surface  of  the  capsule,  or  else  cases 
of  ruptured  capsule,  in  which  the  removal  of  the  opaque  lens  has 
been  effected  by  the  solvent  power  of  the  aqueous  humour ;  while 
on  other  occasions,  it  is  scarcely  to  be  doubted,  that  no  affection  of 
the  lens  or  its  capsule  existed,  but  that  glaucoma,  with  incipient 
amaurosis,  was  mistaken  for  cataract,  and  submitted  to  certain 
modes  of  treatment,  which  not  unfrequently  prove  efficacious  in  re- 
storing, to  a  certain  degree,  the  sensibiUty  of  the  optic  nerve. 


493 

1.  Blood-letting,  and  the  use  of  mercury,  are  certainly  likely  to 
be  attended  with  good  effects,  when  inflammation  is  the  cause  of 
the  opacity  of  the  lens  and  capsule.  The  efficacy  of  these  reme- 
dies, in  some  incipient  spurious  cataracts,  is  fully  ascertained,  but 
in  true  cataract  they  are  seldom  or  never  tried.  Yet  in  certain 
cases  of  this  sort  they  might  prove  beneficial ;  for  instance,  in  the 
Morgagnian  cataract,  which,  according  to  Beer,  results  chiefly  from 
external  irritation. 

2.  Mr.  Ware,  in  one  of  his  notes  to  Wenzel's  Treatise  on  Cata- 
ract, acknowledges  himself  "  wilhng  to  hope,  that  means  may 
hereafter  be  discovered,  by  which  an  opaque  crystalline  may  be 
rendered  transparent,  without  the  performance  of  an^^  operation 
whatsoever ; "  adding,  that  "  the  remedies  which  have  appeared 
to  him  more  effectual  than  others  in  these  cases,  have  been  the  ap- 
plication to  the  eye  itself  of  one  or  two  drops  of  aether,  once  or  twice 
in  the  course  of  the  day ;  and  occasional  frictions  of  the  eye,  over 
the  hd,  with  the  point  of  the  finger,  first  moistened  with  a  weak 
volatile  or  mercurial  liniment." 

M.  Gondret,  to  whom  I  shall  have  occasion  to  refer  as  strongly 
recommending  counter-irritation  as  a  means  of  curing  cataract, 
makes  use  also  of  stimulants  to  the  eye,  especially  electricity  or 
galvanism,  and  ammoniacal  collyria.  Majendie,  who  has  published 
a  paper,  by  M.  Gondret,  on  this  subject,*  regards  the  observations 
of  this  practitioner  as  illustrative  of  his  own  highly  ingenious  ob- 
servations on  the  influence  of  the  fifth  pair  of  nerves  on  the  nutri- 
tion of  the  eye.  When  that  nerve  is  cut  across,  the  nutrition  of 
the  eye  is  interrupted,  the  cornea  becomes  opaque,  and  the  hu- 
mours are  transformed  into  a  substance  reserabhng  curd.  As  sim- 
ilar changes  are  found  to  arise  when  the  nerve  is  unable  from  dis- 
ease, to  execute  its  functions,  it  is  by  no  means  an  unwarrantable 
conjecture,  that  cataract,  which  is  generally  admitted  to  be  in  most 
instances  of  its  occurrence,  an  effect  of  impeded  nutrition,  may 
arise  as  often  from  an  imperfect  action  in  the  nerve  which  controls 
the  nutrition  of  the  eye,  as  from  any  impediment  directly  affecting 
the  nutrient  vessels  of  the  lens.  If  this  be  correct,  then  it  is  ex- 
tremely probable,  that  by  stimulating,  or  otherwise  modifying  the 
action  of  the  fifth  pair,  the  nutrition  of  the  lens  may  be  affected  ; 
so  that  if  want  of  nervous  influence  leads  to  opacity,  excitation 
may  remove  the  tendency  to  cataract,  or  even  restore,  in  some  cases, 
the  natural  transparency. 

3.  M.  Gondret's  paper,  on  the  Treatment  of  Cataract,  just  re- 
ferred to,  contains  a  number  of  cases  not  undeserving  of  attention, 
although  not  one  of  them  is  a  satisfactory  instance  of  true  cataract 
cured  by  the  means  which  he  recommends.  Sincipital  cauteriza- 
tion, by  means  either  of  the  actual  cautery,  or  of  an  ointment 
formed  with  a  very  highly  concentrated  solution  of  ammonia,  is 

*  Journal  de  Physiologic,  Tome  v.  p.  41.     Paris,  1825. 


494 

the  remedy  upon  which  he  chiefly  depends.  I  am  not  at  all  pre- 
pared to  deny  the  efficacy  of  such  powerful  counter-irritation,  in 
changing  the  diseased  action  upon  which  the  production  of  true 
cataract  depends,  but  in  most  of  M.  Gondret's  cases,  especially  in 
those  in  which  the  opacity  visible  behind  the  pupil  was  preceded 
by  inflammation,  there  is  a  suspicion  that  the  disease  was  spurious. 


SECTION  VI. PRELIMINARY    Q.UESTIONS  REGARDING  THE    RE- 
MOVAL OF  CATARACT  BY  OPERATION. 

Before  entering  on  a  particular  description  of  the  different  meth- 
ods of  operating  for  cataract,  there  are  some  questions  of  a  general 
nature  which  require  to  be  considered. 

I.  When  only  one  eye  is  affected  with  this  disease,  ought  we  to 
proceed  to  operate,  or  wait  till  the  other  eye  is  also  attacked  l 
Some  tell  us  that  we  ought  not  to  operate  under  such  circumstan- 
ces, on  account  of  the  difference  in  visual  power  which  would  still 
exist  between  the  two  eyes,  even  were  the  cataract  successfully  re- 
moved ;  a  difference  which,  to  a  certain  degree,  could  no  doubt  be 
remedied  by  the  use  of  a  double-convex  lens,  placed  before  the  eye 
which  had  been  affected  with  cataract,  but  which,  without  this  as- 
sistance, might  render  the  patient's  vision  so  confused,  that  to  see 
well  with  either  eye,  the  other  would  require  to  be  shut.  This, 
then,  is  the  practice  which  is  generally  followed.  But  others  re- 
commend an  immediate  operation,  asserting,  that  by  removing  the 
cataract  from  the  one  eye,  this  disease  may  be  prevented  from  at- 
tacking the  other  ;  or  that  if  already  commencing  in  this  eye,  it 
may  be  removed  by  external  and  internal  remedies,  if  once  the' 
completely  cataractous  eye  were  restored  to  its  office  by  an  opera- 
tion. 

The  sympath}^  whicli  exists  between  the  eyes  is  undoubtedly  very 
strong,  and  we  can  easily  conceive  that  it  may  operate  in  inducing 
similar  affections  of  the  crystalline  lenses,  in  the  saine  way  that  it 
often  appears  to  do  in  producing  similar  diseases  of  the  retinae,  and 
still  less  equivocally  similar  ophthalmias.  Were  it  established  that 
cataract  might  thus  be  produced  sympathetically,  there  could  be  no 
doubt  of  the  propriety  of  removing  a  single  cataract,  even  when 
not  the  shghtest  appearance  of  this  disease  could  be  detected  in  the 
opposite  eye ;  but  the  fact  is  not  established.  The  cataract  of 
old  people  generally  attacks  both  eyes  within  the  period  af  a  few 
months  ;  but  in  middle  hfe,  we  often  meet  with  this  disease, 
in  one  eye,  the  other  having  continued  unaffected  for  many  years. 

II.  When  both  eyes  are  cataractous,  and  equally  or  nearly 
equally  affected,  ought  both  to  be  operated  on  at  the  same  time? 
To  this  question,  my  experience  leads  me  to  answer  in  the  affir- 
mative, if  division  of  the  cataract  is  the  operation  to  be  performed  ; 
but  if  we  mean  to  extract,  I  regard  it  as  much  more  advantageous 


495 

to  operate  on  one  eye  only,  and  wait  the  result  before  touching  the 
other.  Double  extraction  decidedly  exposes  the  eyes  to  greater  risk 
of  inflamraation.  If  we  operate  only  on  one  eye,  and  allow  it  to 
recover,  we  may  possibly  observe,  in  the  course  of  the  operation 
and  recovery,  some  particulars  which  shall  be  essentially  useful  to 
us  in  conducting  the  second  operation,  or  shall  even  lead  us  to 
select  a  different  and  more  suitable  mode  of  operation  for  the  second 
eye. 

III.  Does  the  patient  require  to  undergo  any  particular  course 
of  preparation,  before  submitting  to  an  operation  for  cataract  ?  The 
time  was  when  a  long  and  severe  preparation  was  thought  necessa- 
ry, consisting  in  venesection,  cupping  and  scarifying,  purging,  and 
low  diet.  Now-a-days,  we  have  perhaps  fallen  into  an  opposite 
error,  and  avail  ourselves  too  little  of  the  precautions  which  might 
operate  against  the  supervention  of  inflammation  after  the  operation. 
As  it  is  of  the  highest  importance  that  recovery  should  take  place 
without  the  excitement  of  much  inflammatory  action,  it  may  not 
be  improper  to  bleed  the  patient  once  before  operating,  both  to 
moderate  the  impetus  of  the  circulation,  and  to  discover,  by  the 
appearances  of  the  blood,  whether  there  may  not  be  inflammation 
already  present  in  the  system.  Should  the  blood  prove  sizy,  it 
would  be  highly  imprudent  to  proceed  immediately  to  an  opera- 
tion. 

If  the  bowels  are  disordered,  with  foul  tongue,  deficient  appetite, 
and  headach,  a  dose  of  calomel  every  second  or  third  night,  fol- 
lowed by  salts  and  senna  next  morning,  ought  to  be  given  for  three 
or  four  times,  or  till  the  symptoms  in  question  are  removed.  Even 
if  the  patient  appears  to  be  in  perfect  health,  three  or  four  saline 
purges  ought  to  be  administered  at  proper  intervals,  and  a  strict 
antiphlogistic  plan  of  diet  followed  for  at  least  eight  or  ten  days. 

Immediately  before  the  operation,  the  patient  must  take  no  full 
meal,  and  must  carefully  avoid  all  articles  which  are  difficult  of 
digestion. 

When  once  an  operation  is  resolved  upon,  it  ought  not  to  be  put 
off  without  some  good  cause  ;  for  the  patient's  anxiety  grows  with 
every  hour,  and  he  is  apt  greatly  to  magnify  the  dangers  to  be  ap- 
prehended from  the  operation.  Should  it  necessarily  be  postponed, 
the  patient  must  carefully  guard  against  all  influences  likely  to 
produce  any  rheumatic  or  catarrhal  affection  of  the  eyes.  On  no 
account  must  the  eyes  be  touched  in  the  way  of  operation,  if 
they  appear  affected  in  the  slightest  degree  with  any  sort  of  oph- 
thalmia. 

IV.  Is  there  any  particular  season  of  the  year  more  suited  than 
another  for  operating  7  The  spring  was  formerly  selected  in  pref- 
erence to  any  other  season.  Yet  from  the  prevalence  of  catarrhal, 
rheumatic,  and  inflammatory  affections  at  that  period  of  the  year, 
it  is  perhaps  the  worst  that  could  be  chosen.  Patients  who  are 
liable  to  suffer  from  such  complaints,  ought  to  be  operated  on  in 


496 

dry  summer  weather  only ;  but  a  purely  local  cataract,  occurring 
in  an  individual  otherwise  healthy,  may  be  removed  at  any  season. 

V.  In  cases  of  congenital  cataract,  ought  the  operation  to  be 
delayed  till  the  patient  has  attained  an  age  sufficient  to  enable  hira 
to  give  his  assent,  or  ought  it  to  be  practised  during  infancy  ?  The 
answer  decidedly  is  to  operate  in  infancy.  About  the  age  of  from 
eighteen  months  to  tv/o  years,  the  parts  have  attained  a  degree  of 
resistance,  which  enables  the  surgeon  to  operate  with  greater  pre- 
cision than  at  an  earlier  period,  yet  the  capsule  is  not  so  tough  and 
coriaceous  as  it  becomes  at  a  later  period,  and  especially  after  the 
lens  (as  often  happens  in  congenital  cases)  is  completely  absorbed. 
If  the  operation  is  delayed,  the  eyes,  having  no  distinct  perception 
of  external  objects,  acquire  such  an  inveterate  habit  of  rolling,  that 
for  a  long  time  after  the  pupil  has  been  cleared  by  an  operation,  no 
voluntary  effort  can  control  this  irregular  motion.  The  retina,  too, 
by  a  law  common  to  all  the  structures  of  an  animal  body,  for  want 
of  being  exercised,  fades  in  power. 

Speaking  of  the  results  of  Mr.  Saunders's  operations,  Dr.  Farre 
states,  that  the  sensibility  of  the  eye,  "  in  man}^  of  the  cases  cured 
at  the  ages  of  four  years  and  under,  could  not  be  surpassed  in 
children  who  had  enjoyed  vision  from  birth  ;  but  at  eight  years, 
or  even  earlier,  the  sense  was  evidently  less  active  ;  at  tw^elve  it 
was  still  more  dull ;  and  from  the  age  of  fifteen  and  upwards,  it 
was  generally  very  imperfect,  and  sometimes  the  mere  perception 
of  hght  remained."  *  These  observations  place  beyond  all  contro- 
versy the  propriety  of  an  early  operation  in  cases  of  congenital  cat- 
aract. 


SECTION  VII. POSITION  OF  THE  PATIENT  DURING  OPERATIONS 

FOR    CATARACT,  AND    MODES    OF  FIXING  THE    EYE. 

In  operations  on  the  eye,  much  depends  on  the  position  of 
the  patient,  assistant,  and  operator,  and  on  each  understanding 
what  he  is  to  do.  The  ignorant  forwardness  of  the  assistant,  or 
the  want  of  composure  on  the  part  of  the  patient,  may  in  an  in- 
stant defeat  the  most  perfect  dexterity  of  the  operator. 

The  patient  is  generally  seated  on  a  low  chair  or  stool,  and 
leans  back  his  head  against  the  breast  of  the  assistant,  who  stands 
behind  him,  A  clear  and  steady  hght  is  to  be  chosen,  entering 
the  apartment  by  the  window  opposite  to  which  the  patient  is 
seated,  and  by  no  other.  With  his  hands  he  may  lay  hold  of  the 
seat,  and  he  must  be  cautioned  that  on  no  account  is  he  to  raise 
them  towards  his  eyes.  If  he  cannot  be  depended  on  for  this,  an 
assistant  at  each  side  must  watch  his  hands. 

*  Saunders's  Treatise  on  some  practical  points  relating  to  the  Diseases  of  the  Eye, 
p.  154.    London,  1811. 


497 

To  the  assistant  is  committed  the  charge  of  preventing  the  head 
from  bending  suddenly  backwards,  and  of  supporting  the  upper 
hd.  If  it  is  the  left  eye  which  is  to  be  operated  on,  with  his  right 
hand  he  lays  hold  of  the  patient  by  the  chin,  while  with  the  ex- 
tremities of  the  index  and  middle  fingers  of  his  left  hand  applied 
upon  the  border  of  the  upper  lid,  he  raises  it  as  completely  as  pos- 
sible, and  thus  exposes  the  upper  part  of  the  eyeball.  He  allows 
his  fingers  to  project  so  far  beyond  the  border  of  the  lid,  that  should 
the  patient  endeavour  to  raise  the  eyeball,  it  would  come  into  con- 
tact with  the  fingerS;  and  thus  be  (as  it  were)  scared  back  into  its 
proper  position.  In  general,  the  assistant  does  not  require  to  make 
pressure  on  the  eye  in  any  stage  of  the  operation. 

The  operator  sits  before  the  patient,  on  a  seat  of  such  height 
that  the  patient's  head  is  opposite  to  the  breast  of  the  operator,  who, 
by  this  means,  is  able  to  observe  with  ease  whatever  goes  on  in 
the  eye,  and  is  not  obliged  to  elevate  his  arms  too  much  during  the 
operation.  If  it  is  the  left  eye  which  is  to  be  operated  on,  the  op- 
erator having  tried  the  point  of  the  needle  or  knife,  by  passing  it 
through  a  bit  of  thin  leather,  takes  the  instrument  in  his  right 
hand,  while  w^th  the  index-finger  of  his  left,  he  draws  down  the 
lower  lid,  and  places  the  point  of  that  finger  upon  the  border  of 
the  lid,  so  as  just  to  touch  the  eyeball.  The  middle  finger  he  places 
on  the  caruncula  lachrymalis,  so  as  to  prevent  the  eye  from  turning,  , 
as  it  is  very  apt  to  do,  towards  the  nose,  a  position,  which  if  as- 
sumed after  the  operation  has  commenced,  may  be  productive  of 
very  serious  mischief. 

B}^  the  fingers  of  the  assistant  and  the  operator,  placed  as  has 
been  now  explained,  the  fugitive  eye  is  fixed,  yet  without  pressme. 
To  whatever  side  it  turns,  it  meets  with  the  point  of  a  finger,  except 
towards  the  temple,  where  the  needle  or  the  knife  is  about  to  enter. 

Various  sorts  of  specula,  spikes,  and  hooks,  have  been  invented 
for  fixing  the  eye  ;  but  all  of  them,  except  the  bent  silver  wire, 
commonly  called  Pellier's  speculum,  are  now  discarded.  It  is  oc- 
casionally employed,  especially  in  operations  on  children,  for  sup- 
porting the  upper  hd,  being  applied  either  to  its  outer  surface,  or 
introduced  beneath  its  edge. 

If  it  is  the  right  eye  which  is  to  be  operated  on,  the  operator 
takes  the  needle  or  knife  in  his  left  hand,  unless  he  be  conscious 
of  such  a  want  of  dexterity  as  to  prefer  standing  behind  the  pa- 
tient, so  that  he  may  use  the  right  hand,  the  patient  leaning  his 
head  on  a  pillow  laid  over  the  back  of  a  low  chair.  Some  opera- 
tors prefer  in  all  cases,  that  the  patient  be  laid  along  upon  a  table  ; 
alleging  as  one  reason  for  recommending  this  position,  that  it  is 
found  greatly  more  convenient,  if  the  patient  should  grow  faint 
during  the  operation.  When  the  horizontal  position  is  adopted, 
the  operator  generally  sits  behind  the  head  of  the  patient  when  the 
right  eye  is  to  be  operated  on,  and  stands  by  his  left  side,  if  it  is 
the  left  eye. 

63 


498 

If  with  the  eye  Tv-hich  is  not  to  be  operated  on  the  patient  retains 
any  considerable  deoree  of  vision,  some  tell  us  to  tie  that  eye  up, 
that  both  eyes  may  be  more  at  rest  during  the  operation.  There  is 
no  better  mode,  however,  of  fixing  the  eyes,  than  l^y  desiring  the 
patient  to  look  at  the  operator  who  seizes  that  moment  for  entering 
the  instrument  into  the  eye.  which  is  the  subject  of  the  operation. 
Of  this  advantage  we  are  not  so  certain,  if  the  other  eye  is  tied  up. 


SECTION  VIII. GENERAL     ACCOUNT    OF    THE     OPERATIONS    FOR 

CATARACT. 

There  are  three  kinds  of  operation  for  the  cure  of  cataract.  All 
three  have  undergone  innumerable  modifications;  but  each  is  fotmd- 
ed  on  a  principle  totally  different  from  that  of  the  others. 

In  the  f.rst  place,  there  is  the  mere  removal  of  the  cataract  out  of 
the  axis  of  vision,,  leaving  it  still  in  the  eye.  This  was  formerly 
called  Couching.  We  now  term  it  Displacement.  There  are 
two  varieties  of  it.  viz.  Depression  and  Reclination. 

In  the  second  place,  we  have  the  complete  Extraction  of  the 
cataract. 

And  in  the  tliird  place,  there  is  the  Division  of  the  cataract  into 
frasrments.  which  remain  exposed  to  the  dissolving  influence  of  the 
aqueous  humour. 

It  is  possible  to  perform  each  of  these  three  kinds  of  operation, 
either  through  the  cornea  or  through  the  sclerotica. 

1.  In  Depression  or  Reclination.  we  assign  a  new  situation  to 
the  cataract,  at  the  expense  of  the  vitreous  humour,  which  we 
know  to  be  by  no  means  a  mere  gelatinous  mass,  but  an  organized 
part,  supplied  with  blood-vessels,  and  these  derived  from  the  same 
artery  wliich  nourishes  the  retina.  We  conclude  then,  that  exten- 
sively to  lacerate  the  hyaloid  niembrane;  as  must  be  done  in  forcing 
down  into  ihe  vitreous  humour  such  a  body  as  the  lens,  is  highly 
likely  to  produce  very  serious  injury  to  the  internal  textures  of  the 
eye.  The  mere  shock  of  the  operation  is  likelv  to  excite  inflam- 
mation, disorganize  the  vitreous  humour,  and  induce  insensibility 
of  the  retina.  The  displaced  lens.  also,  is  apt  to  come  into  contact 
with  the  cilic.ry  processes,  and  to  induce  iritis,  followed  by  closure 
of  the  pupil :  or  to  press  against  the  retina,  which  must  necessarily 
cause  amauro-'is.  These  effects  may  follow  more  or  less  quickly. 
If  tht'  displaced  lens  is  firm  and  entire,  or  enclosed  within  the  cap- 
sule, it  will  not  dis-olve  in  the  vitreous  hurrjour.  but  remain  as  a 
permanent  cause  of  irritation  and  chronic  i:itiammation.  hkely  to 
end  sooner  or  later  in  amaurosis. 

In  Depression,  the  lens  is  pushed  directly  below  the  level  of  the 
pu()il.  It  will  follow,  of  course,  the  curvature  of  the  eye,  sweeping 
over  the  corpus  ciliaie  towards  tiie  anterior  edge  of  the  retina,  and 
resting  in  such  a  position,  that  its  anterior  surface  shall  still  be  di- 


499 

reeled  forwards,  and  a  little  downwards.  If  the  lens  is  hard,  and 
the  depression  rudely  performed,  the  retina,  and  even  the  choroid, 
may  readily  be  lacerated  in  this  operation,  and  the  eye  deprived  ii> 
an  instant  of  all  chance  of  recovering  ihe  powei-  of  sight.  If  the 
lens  is  left  resting  upon  the  retina,  it  is  reasonable  to  conclude,  that 
this  of  itself  will  prevent  vision.  Should  it  become  loosened  from 
its  new  situation,  and  rise  a  little  from  the  retina,  the  sensibility  of 
this  membrane  may  perhaps  return ;  but  in  other  cases,  even  after 
the  pressure  is  thus  removed,  the  amaurosis  may  continue. 

After  depression,  the  lens  is  very  partially  covered  by  vitreous 
humour,  and  is  extremely  apt  to  reascend  into  its  original  situation, 
forming  anew  an  impediment  to  vision,  and  again  requiring  to  be 
removed  by  operation. 

To  this  last  objection,  RecUnation  is  not  so  liable.  In  this 
operation,  the  lens  is  made  to  turn  over  into  the  middle,  and  towards 
the  bottom  of  the  vitreous  humour,  so  that  the  surface  of  the  lens, 
which  formerly  was  directed  forwards,  now  looks  upwards,  and 
what  v.'as  the  upper  edge  is  turned  backwards.  Over  the  lens, 
displaced  in  this  manner,  the  vitreous  humour  will  close  much  more 
completely  than  over  the  depressed  lens,  so  that  re-ascension  will  be 
less  likely  to  happen. 

Another  advantage  possessed  by  reclination  is,  that  the  retina 
will  not  be  so  liable  to  be  pressed  on  by  the  cataract,  as  after  depres- 
sion, the  displacement  effected  by  the  former  operation,  carrying 
the  lens  completely  below  the  level  of  the  pupil,  leaving  it  there  in 
the  vitreous  humour,  but  not  pressing  it  into  contact  with  the  floor 
of  the  eyeball. 

On  the  other  hand,  reclination  must  necessaril);^  break  through 
and  destroy  the  hyaloid  membrane  much  more  extensively  than 
depression  :  while,  after  the  former,  as  after  the  latter  operation,  the 
cataract  will  certainly  remain,  like  a  foreign  body,  the  cause  of  con- 
tinued irritation  within  the  eye,  and  in  general,  of  ultiinate  insensi- 
bility to  light. 

II.  Extraction  is  the  complete  removal  of  the  cataract  out  of  the 
eye  at  once,  and  if  easy  of  peiformance,  and  not  ver}^  dangerous 
for  the  eye,  we  would  without  hesitation  pronounce  it  the  operation 
which  ought  to  be  preferred.  But,  to  perform  this  operation, 
whether  through  the  cornea  or  sclerotica,  requires  no  small  degree 
of  dexterity,  and  is  attended  by  very  considerable  danger  to  the  eye. 

If  the  cornea  is  chosen  as  the  part  to  be  opened  for  the  extraction 
of  the  cataract,  the  incision  of  the  cornea,  in  order  that  it  may  after- 
wards unite  without  inflammation,  and  without  any  cicatrice  which 
would  prevent  the  entrance  of  hght,  must  be  perfectly  circular, 
smooth,  and  at  a  regular  distance  from  the  sclerotica,  and  at  the 
same  time,  be  of  sufficient  size  to  allow  the  easy  exit  of  the  cata- 
ract. Both  in  this  first  period  of  the  operation,  and  in  the  subse- 
quent one  of  opening  the  capsule,  the  iris  ought  to  be  left  entirely 
uninjured.     One  of  the  chief  dangers  attached  to  this  operation  is 


500 

that  of  the  loss  of  the  vitreous  humour,  which  is  apt  to  burst  through 
the  membrane  which  naturally  supports  it,  especially  if  this  mem- 
brane is  not  perfectly  sound,  and  to  be  ejected  from  the  eye,  either 
before,  along  with,  or  after  the  cataract.  There  remains,  after  the 
most  favourable  extraction,  an  extensive  wound  of  the  cornea, 
which  we  are  most  anxious  should  close  by  the  first  intention,  and 
without  any  protrusion  of  the  iris.  The  latter  event,  one  of  the 
most  unfortunate  which  can  possibly  happen,  appears  in  some 
cases  to  be  the  consequence,  and  is  always  an  additional  cause  of 
inflammation.  Occasionally  violent  suppurative  inflammation  at- 
tacks the  eye  after  extraction,  so  that  the  natural  structure  of  the 
organ  is  totally  changed.  In  less  severe  cases,  the  iris  suffers  in 
texture,  the  pupil  closes,  or  the  cornea  is  rendered  opaque. 

The  operation  of  extraction  through  the  cornea,  is  too  artificial 
a  piece  of  surgery  to  be  trusted  to  the  hands  of  those  who  have  not 
made  themselves  complete  masters  of  the  subject,  and  already 
shown  a  certain  share  of  natural  or  acquired  dexterity  in  operating 
on  the  eye.  It  is  too  nice  and  dangerous  an  operation  to  be  under- 
taken without  the  utmost  precaution,  composure,  and  steadiness. 

Nor  is  it  likely  that  extraction  through  the  sclerotica  is  less  diffi- 
cult, or  less  dangerous.  Indeed,  this  method  appears  to  be  at  pre- 
sent universally  abandoned,  as  exposing  the  eye  to  the  almost 
certain  loss  of  vitreous  humour,  and  consequent  destruction  of  the 
organ.  Whether  this  risk  is  so  great  as  has  been  imagined,  and 
such  as  should  deter  us  from  an  operation  which  possesses  th.3  ad- 
vantage of  leaving  the  cornea  untouched,  I  have  not  had  sufficient 
opportunities  for  ascertaining. 

III.  Division  is  founded  on  the  fact  that  the  aqueous  humour, 
acting  as  a  menstruum  perpetually  absorbed  and  re-secreted,  has  the 
power  of  completely  dissolving  and  removing  the  crystalline  lens. 
Reasoning  from  this  fact,  and  from  the  anatomy  of  the  parts  con- 
cerned, we  naturally  conclude  that  it  will  be  easy  to  introduce  a 
needle  either  through  the  cornea,  or  through  the  sclerotica,  open 
up  the  anterior  hemisphere  of  the  capsule,  so  as  to  admit  the  aque- 
ous humour,  and  thus  procure  the  solution  of  the  cataract.  Ac- 
cordingly, this  is  regarded  as  the  least  dangerous  mode  of  curing 
this  disease  by  operation.  It  is  not  exempt,  however,  from  disad- 
vantages, trifling  ones,  indeed,  when  compared  to  the  dangers  at- 
tendant on  displacement  or  extraction.  The  torn  capsule  is  apt  to 
reunite,  so  that  the  aqueous  humour  is  excluded  from  the  cataract, 
and  the  solution  ceases.  In  this  case,  the  operation  must  be  re- 
peated, the  lens  itself  divided,  and  the  fragments  brought  into  the 
anterior  chamber.  Iritis  is  not  an  unfrequent  consequence  of  the 
operation  of  division,  and  is  extremely  apt  to  be  attended  by  opacity 
of  the  capsule  from  inflammation.  This  may  take  place  even 
when  the  iritis  is  very  shght;  and  as  the  capsule  is  totally  insolu- 
ble, there  is  no  way  of  removing  its  opaque  shreds  from  behind  the 
pupil,  except  by  displacement  or  extraction.     If  the  cataract  is  hard, 


501 

division  is  impracticable;  but  in  subjects  under  the  age  of  40,  and 
especially  in  young  persons  and  children,  this  method  is  not  merely 
sutiicient  for  the  cure  of  the  disease,  but  is  plainly  the  operation  to 
be  preferred. 

The  conclusions  to  be  drawn  from  this  general  view  of  the  ope- 
rations for  cataract  are  evidently  these  ;  that  each  possesses  its  own 
advantages  and  disadvantages,  and  is  attended  by  its  own  pecuUar 
dangers,  that  one  of  these  operations  will  be  suitable  for  one  case 
of  cataract,  and  another  for  another,  and  that  there  can  be  no  more 
incontestable  proof  of  a  man's  ignorance  of  this  subject  than  his 
asking  which  of  these  operations  we  practise,  or  of  a  man's  being 
a  charlatan  than  his  pretending  to  cure  all  kinds  of  cataract  by  one 
of  these  operations  alone,  modified  by  some  trifling  change  in  the 
manipulations,  or  the  instruments.  Each  of  the  operations  for 
cataract  will,  in  certain  circumstances,  recommend  itself  by  its  own 
peculiar  advantages ;  none  is  to  be  universally  adopted,  and  prac- 
tised to  the  entire  rejection  of  the  others. 


SECTION  IX. DEPRESSION    AND  RECLINATION. 

In  depression,  the  cataract  is  pressed  by  the  needle  almost  per- 
pendicularly under  the  pupil,  somewhat  into  the  vitreous  humour, 
and  to  such  a  depth  as  no  longer  to  form  an  obstacle  to  vision. 
This  operation,  although  by  no  means  the  best,  is  certainly  the 
simplest,  as  it  is  the  most  ancient,  and  therefore  claims  to  be  first 
described. 

If  we  examine  the  figure  of  the  eye,  and  the  proportions  of  its 
several  parts,  it  will  be  evident,  that  there  is  not  suflacient  room  for 
the  lodgment  of  a  large  catai  act  directly  below  the  pupil;  that  if 
merely  depressed,  without  being  reclined  or  turned  over,  the  lens 
will  not  be  sufficiently  covered  by  the  vitreous  humour,  and  will 
be  very  apt  to  reascend  into  its  original  situation  ;  that  if  pressed 
too  much  down,  it  will  be  lodged  upon  the  ciliary  processes  and 
retina,  or  will  be  thrust  between  the  retina  and  the  choroid,  or  even 
through  these  membranes,*  causing  excessive  pain  at  the  moment 
of  the  displacement,  pain  which  has  in  some  instances  been  known 
to  last  through  life;  inducing  vomiting  some  hours  after  the  ope- 
ration, scarcely  to  be  calmed  ;  and  bringing  on  inflammation,  and 
ultimately  amaurosis.  These  appear  to  be  the  unavoidable  effects 
of  incautiously  depressing  a  large  lens.  They  are  carefully  to  be 
distinguished  from  other  bad  effects  which  are  apt  to  attend  this 
operation,  but  which  with  attention  may  be  completely  avoided  ; 
namely,  wounding  of  the  ciliary  processes,  the  retina,  or  the  iridal 
artery,  at  the  moment  of  entering  the  needle  into  the  eye. 

*  Speaking  of  the  situation  of  the  lens  in  those  who  had  been  operated  on  by  de- 
pression, and  whose  eyes  he  dissected  after  death,  Daviel  says,  "  Enfin  il  m'  est  arrive 
de  le  rencontrer  place  entre  la  retine  et  la  choroide,  et  ces  deux  membranes  dechirees 
in  plusieurs  endroits." — Memoires  de  1' Academic  Royale  de  Chirurgie.  12mo.  Tome 
V.  p.  377.    Paris,  1787. 


502 

The  frequent  complaints  made  against  the  operation  of  depres- 
sion led  Willburg*  to  propose  that  modification  of  displacement 
known  by  the  name  of  reclinatiou.  In  this  operation,  the  needle 
being  applied,  not  to  the  vertex,  but  to  the  anterior  surface  of  the 
lens,  or  rather  of  the  capsule,  the  cataract  is  pressed  backwards 
and  downwards  into  the  lower  part  of  the  vitreous  humour,  oppo- 
site to  the  interval  between  the  external  and  inferioi'  straight  mus- 
cles, and  is  left  with  its  anterior  surface  directed  upwards,  its  supe- 
rior edge  backwards.  This  operation  must  necessarily  be  attended 
with  much  disturbance  of  the  vitreous  humour  ;  yet  it  is  in  a  great 
measure  free  from  the  principal  objections  against  depression.  Even 
a  large  cataract  which  has  been  reclined  nmy  lie  imbedded  in  the 
vitreous  humour,  without  being  in  contact  with  any  other  part  of 
the  eye.  and  consequently  without  pressing  directly  against  the  re- 
tina or  the  corpus  ciliare.  It  will  also  be  so  enclosed  and  covered 
by  the  vitreous  humour  that  it  will  not  be  likely  to  reascend. 

I.  Depression  and  Redinaiion  through  the  Cornea. 

la  depression  and  reclination,  the  needle  is  generally  introduced 
through  the  sclerotica  and  choroid.  Some,  however,  have  preferred 
passing  it  through  the  cornea,  but  in  this  way  neither  operation 
can  be  satisfactorily  performed.  If  reclination  be  attempted  through 
the  cornea,  the  needle  being  passed  near  its  lower,  external,  or 
upper  edge,  even  although  the  pupil  is  fully  dilated  by  belladonna, 
it  is  al.most  impossible  to  separate  the  lower  edge  of  the  capsule 
from  its  natural  connexions,  so  that  the  cataract  will  not  be  put 
quite  out  of  sight,  and  will  be  very  apt  to  reascend.  If  the  opera- 
tor, feeling  discontented  on  observing  the  displacement  but  imper- 
fectly effected,  makes  farther  attempts  to  recline  the  cataract  more 
completely,  he  will  probably  bruise  and  perhaps  lacerate  the  iris  in 
such  a  way  as  to  excite  severe  inflammation.  When  partial  ad- 
hesions exist  between  the  iris  and  capsule,  requiring  to  be  separated 
before  proceeding  to  displacement  of  the  cataract,  the  separation 
cannot  be  effected  by  the  needle  passed  through  the  cornea. 

II.  Depression  and   Reclination   through  the  Sclerotica. 

On  the  evening  previous  to  the  operation,  extract  of  belladonna, 
moistened  to  the  consistence  of  cream,  is  to  be  smeared  on  the  eye- 
brow and  eyelids,  and  allowed  to  remain  till  about  half  an  hour  be- 
fore the  operation,  when  it  is  to  be  washed  off  with  a  sponge  and 
tepid  water.  If  the  pupil  is  not  b}'  this  time  fully  dilated,  a  little 
filtered  solution  of  extract  of  belladonna  in  water  is  to  be  dropped 
upon  the  conjunctiva,  not  rudely  dashed  in,  with  a  hair-pencil. 

The  instrument  best  adapted  for  depression  and  reclination  is 
either  a  straight  lance-shaped  needle,  such  as  Beer's,  or  a  bent 
needle,  such  as  Scarpa's.     The  straight  needle  is   more  easily  in- 

*  Betrachtung  Uber  die  bisherigen  gewohnlichen  Operationen  des  Staares.  NOm- 
berg,  1785. 


503 

troduced  and  withdrawn,  the  bent  one  takes  a  better  hold  of  the 
cataract.  The  lance-shaped,  or  the  bent  part  of  the  needle  should 
measure  not  more  than  |th  of  an  inch  in  length,  nor  more  than 
l-20th  of  an  inch  in  breadth  at  its  broadest  part.  The  neck  should 
be  perfectly  round,  so  that  after  the  instrument  is  once  introduced 
into  the  eye,  it  may  be  turned  in  any  direction  without  distorting 
or  enlarging  the  aperture  by  which  it  has  been  passed  through  the 
sclerotica  and  choroid.  The  chisel-shaped  instruments  sold  in  the 
shops,  are  totally  inadmissible,  as  they  cannot  be  turned  round  on 
their  axis  without  greatly  injuring  the  tunics  through  which  they 
have  been  passed,  and  cannot,  without  being  turned  round,  exe- 
cute the  necessary  manipulations  of  depression  or  reclination. 

Each  of  these  operations  is  divided  into  three  periods,  which  must 
not  only  be  distinctly  understood  by  the  surgeon,  but  carefully  ob- 
served by  him  in  practice.  In  the  first  period,  the  needle  is  intro- 
duced through  the  tunics,  and  into  the  vitreous  humour.  In  the 
second,  the  instrument  enters  the  posterior  chamber,  and  is  applied 
to  the  cataract.  In  the  tidrd,  the  actual  displacement  is  effected. 
It  is  only  in  the  third  period,  that  rechnation  differs  from  depression. 

ist  Period.  The  needle  must  enter  the  eye  so  as  to  wound  no- 
thing but  what  cannot  be  avoided,  else  we  may  be  prevented  from 
satisfactorily  executing  the  remaining  parts  of  the  operation,  or  may 
inflict  serious  and  irreparable  injury. 

The  parts  which  must  be  wounded  are  the  conjunctiva,  sclerotica, 
choroid,  and  vitreous  humour.  The  parts  to  be  avoided  are  the 
ciliary  processes,  the  retina,  the  iridal  or  long  ciliary  artery,  the  lens, 
and  as  much  as  possible  the  vessels  of  the  pars  non-plicata  of  the 
corpus  ciliare.  If  the  cihar}^  processes,  the  iridal  artery,  or  several 
of  the  choroidal  arteries  be  wounded,  haemorrhage  is  apt  to  take 
place  into  the  eye,  filling  in  an  instant  the  aqueous  chambers  with 
blood,  preventing  the  operator  from  seeing  the  cataract  and  the  nee- 
dle with  sufficient  distinctness,  and  thus  obliging  him,  if  he  con- 
tinues the  operation,  to  perform  it  as  if  in  the  dark.  We  are  taught 
to  believe  that  the  retina  is  insensible  to  mechanical  irritation,  so 
that  the  wounding  of  it  with  the  needle  should  not  be  productive  of 
any  pain  ;  but  as  we  know  not  how  far  the  violent  vomiting  which 
not  unfrequently  follows  displacement,  may  sometimes  be  owing  to 
touching  the  retina  with  the  needle,  or  how  far  its  sentient  power 
may  afterwards  be  affected  from  being  wounded,  we  should  always 
avoid  a  part  of  the  eye,  the  integrity  of  vhich  it  is  reasonable  to 
conclude,  must  be  of  the  highest  importance.  If  the  needle  is  di- 
rected towards  the  cataract  in  the  first  period,  it  is  apt  to  enter  the 
substance  of  the  lens,  so  that  on  attempting  to  proceed  with  the  ope- 
ration, the  whole  cataract  moves  towards  the  pupil ;  an  inconvenient 
and  awkward  occurrence,  requiring  the  needle  to  be  withdrawn  a 
little  and  freed  from  the  lens,  beiore  it  can  be  introduced  into  the 
posterior  chamber. 

All  these  errors  may  be  avoided  by  attending  to  the  following 
rules. 


504 

1.  Taking-  the  lance-shaped  needle  in  his  right  hand,  if  it  is  the 
left  eye  which  is  to  be  operated  on,  and  vice  versa,  the  operator 
holds  it  with  the  one  flat  surface  looking  upwards  and  the  other 
downwards,  in  order  that  in  passing  through  the  pars  non-plicata 
of  the  corpus  ciliare,  it  may  divide  as  few  of  the  choroidal  arteries 
as  possible. 

2.  The  lids  being  fixed  by  the  fingers  of  the  assistant  and  opera- 
tor, in  the  manner  specified  at  page  497,  the  operator  leans  with  his 
little  finger  on  the  cheek  of  the  patient  as  on  a  point  of  support,  in 
order  to  prevent  the  needle  from  sinking'  suddenly  and  to  too  great 
a  depth  into  the  eye. 

3.  The  point  of  the  instrument  is  to  be  directed  towards  the  cen- 
tre of  the  vitreous  humour,  thus  completely  avoiding  the  lens. 

4.  The  needle  is  to  be  entered  at  the  distance  of  one-eighth  of 
an  inch  behind  the  temporal  edge  of  the  cornea.  If  this  rule  is  not 
attended  to,  but  the  instrument  is  entered  nearer  to  the  cornea  or 
farther  from  it,  the  cihary  processes  on  the  one  hand,  and  on  the 
other  the  retina,  can  scarcely  escape  being;  injured. 

5.  In  order  to  avoid  the  iridal  artery,  the  needle  is  to  be  entered 
not  in  the  equator  of  the  eye,  but  one-tenth  of  an  inch  below  that 
line. 

6.  As  soon  as  the  needle  has  penetrated  to  the  depth  of  one-fifth 
of  an  inch,  or  in  other  words,  as  soon  as  the  lance-shaped  part  of  it 
is  fairly  within  the  choroid,  the  first  period  of  the  operation  is  com- 
pleted, and  the  instrument  is  on  no  account  to  be  thrust  deeper  into 
the  vitreous  humour. 

2d  Period.  The  second  period  of  the  operation  commences  with 
a  double  motion  of  the  nsedle,  by  which,  in  the  first  place,  it  is 
made  to  perform  a  quarter  of  a  revolution  on  its  axis,  so  that  one  of 
its  flat  surfaces  comes  to  be  turned  forwards  and  the  other  back- 
wards, while  at  the  same  time  its  handle  is  carried  back  towards  the 
temple,  and  the  point  of  the  instrument  forwards.  This  brings  the 
point  of  the  needle  between  the  fringed  circular  edge  of  the  cihary 
processes  and  the  circumference  of  the  lens.  The  operator  now  slowly 
pushes  on  the  needle  between  these  parts  into  the  posterior  chamber. 
He  sees  its  point  advancing  from  behind  the  temporal  edge  of  the 
pupil,  and  carries  it  on  through  the  posterior  chamber,  across  the 
pupil,  till  its  point  is  hid  behind  the  nasal  portion  of  the  iris.  The 
posterior  flat  surface  of  the  needle  is  thus  applied  to  the  anterior  sur- 
face of  the  anterior  hemisphere  of  the  capsule. 

SfZ  Period.  The  rest  of  the  operation  differs  according  as  the 
cataract  is  to  be  depressed  or  reclined. 

If  the  operator  chooses  to  depress,  he  elevates  the  point  of  the 
needle  by  lowering  its  handle,  till  the  point  reaches  the  superior 
edge  of  the  lens,  and  then  he  gives  the  instrument  a  quarter-turn, 
so  as  to  apply  the  flat  side  of  it  to  the  vertex  of  the  cataract.  The 
handle  is  now  gradually  elevated,  the  point  depressed ;  the  cataract 
descends  from  behind  the  pupil ;  its  course  is  downwards,  and  a 


505 

little  outwards  and  backwards  ;  it  is  to  be  depressed  till  it  is  no 
longer  in  sight,  which  will  always  be  effected  when  the  handle  of 
the  needle  has  been  so  far  elevated,  that  the  direction  of  the  whole 
instrument  has  become  horizontal.  Beyond  this,  there  must  be 
no  farther  depression.  There  is  no  room  to  carry  the  cataract 
farther  in  the  direction  of  depression.  Raise  the  handle  higher 
than  the  horizontal  position,  the  cataract  is  pressed  through  the 
retina,  and  vision  extinguished  by  the  very  attempt  which  is  made 
to  restore  it. 

For  the  space  of  a  minute  or  two,  the  needle  is  to  be  kept  in 
contact  with  the  depressed  cataract.*  Its  point  is  then  to  be  gently 
raised,  the  operator  taking  notice  whether  the  cataract  reascends, 
or  remains  depressed.  If  it  reascends,  the  depression  must  be  re- 
peated. 

In  this  operation,  and  also  in  reclination,  it  is  desirable  that  the 
capsule  should  be  displaced  along  with  the  opaque  lens.  It  is 
probable,  however,  that  in  many  instances,  the  capsule  is  merely 
torn  by  the  needle,  and  its  shreds  left  attached  to  the  circle  of  the 
ciliary  processes.  These  shreds,  being  highly  elastic,  will  roll  them- 
selves up,  and  prove  no  impediment  to  vision,  unless  inflammation 
comes  on  and  renders  them  opaque,  in  which  case  they  will  form 
a  secondary  capsular  cataract.  After  the  displacement  is  accom- 
plished, and  just  before  withdrawing  the  needle  from  the  eye,  it  is 
proper  to  turn  the  point  of  the  instrument  towards  the  cornea,  and 
to  move  it  three  or  four  times  round  within  the  pupil,  so  as  to  en- 
sure the  division  of  the  capsule,  if  it  had  been  left  ifi  situ.  The 
needle  is  then  to  be  removed  from  the  eye,  in  the  same  position  as 
to  its  surfaces  in  which  it  was  introduced. 

If  the  surgeon  prefers  reclination  to  depression,  he  commences 
the  third  period  of  the  operation  by  raising  the  point  of  the  needle 
not  more  than  the  tenth  of  an  inch  above  the  transverse  diameter 
of  the  lens,  and  then  immediately  proceeds  to  recUne  the  cataract 
by  moving  the  handle  of  the  instrument  upwards  and  forwards, 
while  its  point  of  course  passes  downwards  and  backwards.  By 
this  manipulation,  the  cataract  is  made  to  fall  backwards  into  the 
vitreous  humour,  and  at  the  same  time  downwards  and  a  little  out- 
wards. The  position  of  the  needle  at  the  end  of  reclination,  is 
very  different  from  its  position  at  the  end  of  depression.  In  the 
latter,  it  is  horizontal ;  in  the  former,  the  handle  is  pointing  up- 
wards, outwards,  and  forwards,  nearly  in  a  Une  with  the  temple  of 
the  operator. 

Manner  of  using  the  Needle.  L  This  instrument  is  to  be 
held  extremely  lightly  in  the  hand,  so  that  it  may  be  moved  easily 
in  all  directions.     If  it  be  grasped  firmly  by  the  fingers,  the  operator 

*  Guy  de  Chauliac,  who  composed  his  work  on  Surgery  in  1363,  gives  the  follow- 
ing direction  to  the  operator,  regarding  the  time  during  which  he  should  keep  the 
needle  in  contact  with  the  depressed  cataract.  "II  la  tiendra  logee  avec  1'  eguille 
pendant  le  temps  qu'  il  faut  mettre  a  dire  trois  fois  le  Pater,  ou  une  fois  le  Miserere.''^ 

64 


506  , 

I 

has  comparatively  no  power  over  it,  and  is  unable  to  execute  the    ' 
delicate  movements  required  in  the  operations  of  displacement. 

2.  When  once  the  needle  is  introduced  into  the  eye,  no  part  of 
the  depression  or  rechnation  is  to  be  executed  by  a  motion  of  the 
whole  instrument  in  one  direction ;  but  the  point  is  always  to  be 
moved  in  one  direction,  and  the  handle  in  another,  so  that  the 
needle  forms  a  lever  of  the  first  kind,  the  sclerotica  being  the  ful- 
crum. Upon  this  fulcrum,  the  instrument  ought  to  be  moved  with 
the  least  degree  of  pressure  possible,  and  without  any  dragging  of 
the  eye. 

Modifications  of  depression  atid  reclination  according  to 
varieties  of  cataract.  1.  When  the  cataractous  lens  is  friable, 
and  breaks  into  fragments  under  the  pressure  of  the  needle,  or 
when  it  is  soft,  so  that  the  needle  passes  through  it  without  dis- 
placing it,  displacement  ought  to  be  altogether,  or  in  a  great  mea- 
sure, abandoned,  and  the  operation  of  division  immediately  substi- 
tuted in  its  room.  The  anterior  hemisphere  of  the  capsule,  is  care- 
fully to  be  lacerated,  and  its  central  part,  if  possible,  destroyed  ;  the 
fragments  of  the  friable  lens  will  often  pass  almost  of  themselves,^ 
through  the  lacerated  opening,  and  through  the  pupil  into  the  an- 
terior chamber,  where  they  will  speedily  be  dissolved.  If  the  nu- 
cleus of  the  lens,  however,  appears  to  be  hard,  we  have  our  choice 
either  to  displace  it,  or  leave  it  in  situ  exposed  to  the  action  of  the 
aqueous  humour.  The  pieces  into  which  a  soft  gelatinous  lens 
may  be  divided,  are  not  so  easily  scattered  by  the  application  of  the 
needle  ;  and  in  such  a  case,  it  is  better  not  to  attempt  too  much, 
but  rather  confine  ourselves  to  the  destruction  of  the  anterior  hem- 
isphere of  the  capsule,  reserving  for  a  subsequent  operation  the 
division  of  the  lens  and  dispersion  of  its  fragments. 

2.  If  displacement  be  attempted  in  cases  of  capsulo-lenticular 
cataract,  it  not  uufrequently  happens  that  the  instant  the  capsule 
is  opened  with  the  needle,  the  lens  being  in  the  state  of  a  fluid,  is- 
poured  into  the  aqueous  humour.  In  a  day  or  two  after,  the  aque- 
ous humour  will  again  be  of  its  natural  transparenc)^,  the  fluid  lens 
having  been  absorbed  ;  but  unless  something  more  has  been  done 
at  the  time  of  the  operation  than  merely  puncturing  the  capsule, 
vision  will  still  be  interrupted  by  the  capsular  part  of  the  cataract. 
When  we  observe,  therefore,  that  the  dissolved  lens  is  escaping  into 
the  aqueous  humour,  we  should  endeavour  as  completely  as  this 
state  of  matters  will  allow,  to  lacerate  and  destroy  the  anterior  hemis- 
phere of  the  capsule  ;  and  should  we  find  after  the  absorption  of 
the  dissolved  lens  is  effected,  that  the  central  aperture  in  the  capsule 
is  insufficient,  either  another  attempt  must  be  made  with  the  needle,^ 
to  clear  away  as  much  of  it  as  shall  secure  the  transmission  of  the 
rays  of  light  to  the  retina,  or  it  must  be  extracted  through  a  small 
incision  of  the  cornea. 

3.  We  sometimes  have  to  do  with  cases  of  cataract,  in  which 
the  edge  of  the  pupil,  in  consequence  of  previous  iritis,  is  partially 


507 

or  completely  adherent  to  the  capsule.  When  the  adhesion  era- 
braces  the  whole  circumference  of  the  pupil,  to  separate  the  capsule 
is  almost  impossible,*  so  that  as  far  as  the  capsule  is  concerned,  the 
formation  of  a  cenUal  opening  in  it  is  all  that  we  should  attempt. 
The  lens  we  displace  or  divide,  according  to  the  estimate  we  are 
led  to  form  of  its  consistence.  When  the  edge  of  the  pupil,  on  the 
other  hand,  is  bound  to  the  capsule  in  one  or  two  points  only,  as 
will  be  rendered  evident  on  bringing  the  iris  under  the  influence  of 
belladonna,  we  endeavour  first  of  all  to  cut  across  these  adhesions 
with  the  edge  of  the  needle,  then  open  up  the  centre  of  the  capsule, 
and  lastly,  displace  the  opaque  lens.  Before  withdrawing  the 
needle,  the  central  aperture  of  the  capsule  may  be  enlarged  or  com- 
pleted, unless  we  judge  that  enough  has  already  been  done,  and 
that  any  thing  farthef  should  be  left  to  another  operation,  after  an 
interval  of  some  weeks  or  months.  The  cutting  across  of  the  ad- 
hesions between  the  iris  and  the  capsule,  is  generally  attended  with 
some  discharge  of  blood. 

4.  Cases  occur  m  which  the  cataract  instantly  reascends, 
whenever  the  needle  is  raised  in  order  to  withdraw  it  from  the  eye. 
Such  an  occurrence  has  been  ascribed  to  a  greater  degree  of  adhe- 
sion than  is  natural  between  the  crystalline  capsule  and  the  vitreous 
humour,  and  has  been  designated  elastic  cataract.  In  such  a 
case,  we  allow  the  cataract  to  resume  the  situation  whence  it  l;:.d 
been  forced  by  the  application  of  the  needle ;  we  then  carry  the 
instrument  over  the  upper  edge  of  the  lens,  and  down  behind  the 
posterior  hemisphere  of  the  capsule;  we  move  it  upwards  and 
downwards,  so  as  to  destroy  the  adhesion  of  the  capsule  to  the 
hyaloid  membrane,  bring  up  the  needle  from  under  the  cataract 
into  the  posterior  chamber,  and  then  repeat  the  displacement  as  be- 
fore. 

After-treatment.  1.  Experiments  on  the  degree  of  vision  re- 
covered by  means  of  the  operation  which  has  just  been  performed, 
are  not  advisable,  as  in  the  endeavours  which  the  patient  makes  to 
discover  the  objects  presented  to  him,  the  muscles  of  the  eye  are 
necessarily  called  into  action,  and  this  is  apt  to  be  followed  hy  re-as- 
cension of  the  cataract. 

2.  The  eyes  are  to  be  shaded  by  means  of  a  light  Unen  com- 
press, fixed  by  a  roller  going  round  the  head,  or  pinned  to  the 
night-cap, 

3.  Rest  is  to  be  enjoined,  both  of  the  eyes  and  of  the  head,  for 
some  days ;  the  patient  lying  in  bed,  or  sitting  in  a  chair.  Tho 
room  is  to  be  kept  moderately  dark.  The  food  is  to  be  of  any 
easily  digested  kind,  not  too  nourishing,  nor  of  such  a  sort  as  to  re- 
quire chewing. 

4.  After  three  or  four  days,  the  eyes  may  be  protected  from  the 

*  Mr.  Hey  relates  an  interesting  case,  in  which  after  twelve  operations  with  the 
needle,  he  succeeded  in  detaching  the  capsule  under  such  circumstances,  and  restored 
vision. — Practical  Observations  in  Surgery,  p.  82.    London,  1803. 


508 

light  by  a  green  bonnet-shade,  but  ought  not  for  eight  or  ten  days 
longer  to  be  employed  in  examining  objects.  After  this  period, 
they  are  gradually  to  be  brought  into  use,  the  patient  taking  care 
to  avoid  whatever  excites  pain  or  redness  of  the  eyes,  or  gives  rise 
to  epiphora. 

Accidents  during  or  consequent  to  the  operation  of  displace- 
ment. 1.  One  cf  the  least  considerable  of  the  accidents  which  are 
apt  to  follow  these  operations,  is  the  formation  of  a  small  thrombus 
under  the  conjunctiva,  in  consequence  of  one  of  the  visible  vessels 
of  the  eye  having  been  wounded  by  the  needle,  a  thing  which  may 
easily  be  avoided.  Should  such  a  thrombus  follow,  it  is  to  be  left 
to  itself ;  tlie  blood  contained  in  it  will  speedily  be  absorbed. 

2.  A  small  fungous  excrescence  sometimes  rises  over  the  wound 
made  by  the  entrance  of  the  needle  through  the  coats  of  the  eye. 
It  may  be  touched  once-a-day  with  a  solution  of  nitrate  of  silver,  or 
if  this  proves  ineffectual,  with  the  same  substance  in  the  solid  state. 

3.  Effusion  of  blood  into  the  chambers  of  the  eye  is  by  no  means 
a  frequent  occurrence  in  the  operations  of  displacement.  Even 
when  the  iridal  artery  is  divided,  or  the  ciliary  processes  touched, 
the  bleeding  generally  tends  more  to  escape  by  the  wound  than  to 
flow  into  the  interior  of  the  eye.  At  the  same  time,  it  cannot  be 
denied  that  haemorrhage  into  the  aqueous  humour,  suddenly  ob- 
scuring the  field  of  operation,  does  occasionally  occur.  In  the  ma- 
jority of  cases,  the  blood  may  safely  be  left  to  be  removed  by  ab- 
sorption. Rarely  indeed  is  it  in  such  quantity  as  to  produce  a  feel- 
ing of  pain  or  distension,  or  render  necessary  an  opening  at  the 
edge  of  the  cornea,  with  the  extraction-knife,  for  its  evacuation. 

4.  If  the  operator  has  either  entered  the  needle  in  an  improper 
direction,  or  plunged  it  too  deep  at  first  into  the  eye,  the  point  of  the 
instrument  is  apt  to  be  buried  in  the  substance  of  the  lens,  so  that 
on  attempting  to  proceed  with  the  operation,  the  whole  cataract 
moves  forward  towards  the  cornea.  When  the  operator  observes 
that  this  is  the  case,  he  must  turn  the  needle  several  times  round 
on  its  axis,  so  as  to  free  it  from  the  lens,  withdraw  it  a  little,  and 
then  proceed  to  the  second  period  of  the  operation,  in  the  usual 
manner. 

5.  It  sometimes  happens,  that  on  attempting  to  depress  or  recline 
the  lens,  it  is  suddenly  tilted  forward  through  the  pupil.  When 
this  is  the  case,  it  may  be  possible,  with  some  difficulty,  to  carry  it 
back  again  to  its  former  situation,  and  then  to  displace  it  as  had 
been  intended.  I  consider  it  to  be  better  practice,  however,  imme- 
diately to  extract  the  lens.  For  this  purpose,  the  operator  should 
keep  it  pressed  against  the  cornea  with  the  needle,  make  a  section 
of  one-third  of  the  circumference  of  the  cornea  with  the  extraction- 
knife,  and  laying  hold  of  the  lens  with  a  hook,  remove  it  from  the 
eye. 

6.  Violent  bilious  vomiting  in  the  course  of  a  few  hours,  or  dur- 
ing the  first  night  after  the  operation,  is  a  frequent  consequence  of 


509 

depression  and  reclination.  This  symptom  has  been  attributed  to 
various  causes,  as  injury  of  the  cihary  nerves,  or  of  the  retina,  at 
the  moment  of  entering  the  needle,  and  pressure  on  the  retina,  or 
laceration  of  this  part,  from  displacement  rudely  and  ignorantly 
performed.  The  ordinary  means  for  /checking  vomiting  are  to  be 
adopted,  especially  small  doses  of  opium,  frequently  repeated.  Blood- 
letting ought  also  to  be  had  recourse  to,  as  inflammation  scarcely 
ever  fails  to  occur  in  those  cases  where  violent  vomiting  is  excited 
by  the  operation. 

7.  Inflammation  of  the  retina  and  of  the  iris  is  to  be  apprehended 
after  the  operations  of  displacement,  especially  when  the  manipula- 
tions have  been  rudely  executed,  and  the  needle  kept  long  in  the 
eye.  Severe  pain  in  the  eye  and  round  the  orbit,  coming  on  dur- 
ing the  night,  is  generally  the  first  symptom  indicative  of  internal 
inflammation,  after  any  operation  on  the  eye.  The  sclerotica  and 
conjunctiva  become  red,  the  colour  of  the  iris  changes,  the  pupil 
contracts,  lymph  is  effused,  the  remnants  of  the  loose  capsule  be- 
come opaque  and  coalesce,  vision  becomes  extremely  indistinct,  and 
unless  proper  means  of  cure  are  adopted,  onyx,  hypopium,  and  de- 
struction of  the  eye,  may  ensue.  Free  blood-letting,  both  general 
and  local ;  opium,  internally  and  externally ;  calomel,  so  as  speed- 
ily to  affect  the  mouth ;  and  belladonna,  to  dilate  the  pupil,  are  the 
remedies  chiefly  to  be  relied  on. 

Chronic  inflammation  of  the  internal  textures  of  the  eye  is  a  fre- 
quent consequence  of  depression  or  reclination.  It  is  not  attended 
by  much  pain,  but  prevents  the  eye  from  ever  attaining  a  degree  of 
healthiness  sufficient  to  render  it  useful.  Epiphora,  varicose  dilata- 
tion of  the  external  blood-vessels  of  the  eye,  and  in  general  a  con- 
tracted, but  sometimes  a  dilated  pupil,  attend  this  state  of  the  organ, 
the  true  remedy  for  which  would  be  the  entire  removal  of  the  lens, 
which  lying  in  the  vitreous  humour,  operates  exactly  as  a  foreign 
substance  would  do  in  the  same  situation. 

8.  Amaurosis,  with  dissolution  of  the  vitreous  humour,  irregu- 
larly dilated  pupil,  haziness  of  the  cornea,  and  varicose  dilatation  of 
the  external  blood-vessels  of  the  eye,  is  a  common  result  of  the 
operations  of  displacement.  If  the  retina  is  pressed  upon  by  a  firm 
lens,  which  has  been  depressed  or  reclined,  insensibility  to  light  is 
the  necessary  consequence. 

It  sometimes  happens,  however,  that  after  some  days  or  weeks, 
the  lens  rises  a  little  in  the  vitreous  humour,  the  retina  is  thereby 
relieved,  and  the  power  of  vision  returns.  Yet  this  result  does  not 
always  follow ;  the  lens  may  reascend,  and  the  retina  remain  in- 
sensible. If  the  practitioner  who  has  performed  depression  or 
reclination,  out  of  a  too  favourable  opinion  perhaps  of  these  opera- 
tions, sees  reason  to  suspect  that  the  very  means  which  he  had 
adopted  for  restoring  vision,  threatens  to  destroy  it,  he  ought  not 
to  hesitate  about  withdrawing  the  displaced  lens  from  the  eye  en- 
tirely.    Introducing  a  bent  needle  through  the  sclerotica,  the  cata- 


510 

ract  is  to  be  raised  into  its  former  situation,  pressed  forward  through 
the  pupil,  and  kept  in  contact  with  the  cornea  till  a  section  is  made, 
a  hook  introduced,  and  the  lens  laid  hold  of,  so  that  it  may  be 
extracted. 

9.  If  the  lens  is  displaced,  with  its  capsule  entire,  it  will  suffer 
no  solution  in  the  vitreous  humour ;  even  stript  of  the  capsule,  a 
hard  lens  will  remain  unchanged  for  a  great  length  of  time.  Beer 
saw  a  lens,  which  had  been  depressed  thirty  years  before  by  Hil- 
mer,  reascend  in  consequence  of  a  fall  upon  the  head ;  and  in 
many  instances,  he  had  found  cataracts  on  dissection,  lying  in  the 
vitreous  humour,  firm,  and  only  slightly  contracted,  the  lenticular 
part  bearing  no  marks  of  solution,  and  the  capsular  none  of  mace- 
ration.* 

Re-ascension  of  a  depressed  or  reclined  cataract,  is  so  common 
an  occurrence,  that  some  have  gone  the  length  of  speaking  of  the 
operations  of  displacement,  as  affording  only  a  palliative  cure.t 
Re-ascension  may  take  place  at  any  period  after  the  operation,  but 
is  more  apt  to  happen  within  the  first  fortnight  than  afterwards. 
The  plan  usually  adopted  by  those  who  have  practised  displace- 
ment, has  been  to  repeat  the  same  operation  after  each  re-ascension, 
till  the  lens  has  fairly  settled  in  the  situation  which  they  assigned 
to  it.  Thus  we  find  Mr.  Hey  couching  some  of  his  patients  six 
or  seven  times  over.t  I  shall  not  pretend  to  say,  that  in  all  cases 
of  reascension,  extraction  through  a  section  of  about  a  third  of  the 
circumference  of  the  cornea  should  be  practised  ;  but  of  this,  there 
can  be  no  doubt,  that  it  is  proper  in  all  such  cases,  if  extraction  is 
not  immediately  resolved  upon,  to  wait  for  a  few  weeks  and  watch 
what  may  be  the  effects  of  the  aqueous  humour  on  the  cataract. 
It  is  quite  evident,  that  many  of  the  cures  attempted  by  displace- 
ment, and  recorded  as  instances  favourable  to  the  plan  of  couching, 
in  preference  to  extracting,  were  actually  accomplished  by  the  dis- 
solution of  the  lens  after  re-ascension.  Thus,  Mr.  Hey  tells  us, 
that  in  one  of  his  patients,  "  the  cataract  in  the  left  eye  appeared 
again  ;  but  in  a  few  weeks  it  became  sensibly  wasted."  §  Should 
there  be  no  appearance  of  dissolution  after  some  weeks,  it  will  be- 
come a  question  whether  a  repetition  of  displacement  should  be 
adopted,  or  an  attempt  made  to  extract  the  cataract.  The  latter 
cannot  be  safely  attempted  in  the  ordinary  way,  that  is,  by  a  sec- 
tion of  half  the  circumference  of  the  cornea,  else  the  vitreous  hu- 
mour, in  consequence  of  what  it  has  suffered  from  the  previous 
displacement,  will  almost  certainly  be  evacuated ;  but  the  needle 
must  be  employed  to  press  the  cataract  through  the  pupil,  and  a 
third  part  only  of  the  circumference  of  the  cornea  opened  for  its 
extraction  with  the  hook. 

*  Lehre  von  den  Augenkrankheiten.     Vol.  ii.  p.  363.     Wien,  1817.  t  Ibid. 

t  Practical  Observations  in  Surgery,  pp.  79  and  81.     London,  1803. 
§  Practical  Observations  in  Surgery,  p.  77.    London,  1803. 


511 

SECTION  X. EXTRACTION. 

I.  Extraction  through  a  semicircular  incision  of  the  Cornea. 

Extraction  of  the  cataract,  through  an  incision  of  the  cornea, 
appears  to  have  been  first  practised  as  a  regular  method  of  re- 
moving this  disease,  by  Daviel,  a  French  navy  surgeon,  who  had 
settled  at  Marseilles,  about  the  middle  of  last  century.  He  con- 
fesses that  he  had  taken  the  hint  of  this  mode  of  operating  from 
Petit,*  who  in  1708,  had  opened  the  cornea  to  extract  an  opaque 
lens  which  had  come  forward  into  the  anterior  chamber;  and  that 
he  had  felt  himself  urged  to  devise  some  new  mode  of  operating 
for  cataract,  by  the  want  of  success  which  he  found  to  attend  the 
operation  of  couching,  and  the  destruction  of  the  internal  textures 
of  the  eye,  disclosed  upon  dissecting  the  eyes  of  those  who  had 
undergone  this  opera tion.f 

Daviel  commenced  his  operation,  by  passing  a  broad  needle  or 
small  lancet  into  the  anterior  chamber,  close  to  the  lower  edge  of 
the  cornea.  He  then  enlarged  the  incision,  thus  made,  by  another 
instrument  somewhat  similar  to  the  former,  but  which  being  sharp 
on  the  edges  only  and  blunt  at  the  point,  could  with  less  danger 
to  the  iris  be  introduced  into  the  anterior  chamber.  He  completed 
the  semicircular  section  with  bent  probe-pointed  scissors.  The  in- 
conveniences arising  from  the  employment  of  so  many  instruments 
were  perceived,  and  speedily  remedied  by  Palucci,  La  Faye,  Sharp, 
and  others,  who  substituted  a  single  knife,  which  being  entered  at 
the  temporal  edge  of  the  cornea,  passed  through  the  anterior  cham- 
ber, made  its  exit  at  the  nasal  edge  of  the  cornea,  and  either  by  its 
progressive  motion  or  by  being  pressed  downwards,  completed  a 
crescentic  incision  parallel  to  the  lower  edge  of  the  cornea. 

The  operation  of  extraction  divides  itself  into  three  periods.  In 
the  first,  the  cornea  is  opened  with  the  knife.  In  the  second,  the 
anterior  hemisphere  of  the  capsule  is  opened,  or  rather  destroyed 
as  much  as  possible.  In  the  third,  the  exit  of  the  cataract,  or  the 
extraction  properly  so  called,  is  accomphshed.  Some  dexterous  and 
experienced  operators  have  attempted  to  run  these  different  periods 
together ;  but  it  is  absolutely  necessary  to  study  them  individually, 
and  it  is  always  safer  to  execute  each  of  the  three  objects  above 
stated,  deliberately  and  by  itself 

*  Memoires  de  rAcademie  Royale  des  Sciences,  Annee  1708.  p.  311.  Amsterdam. 
1750. 

t  Memoires  de  1' Academie  Royale  de  Chirurgie.  12  mo.  Tomev.  p.  369.  Paris, 
1787. — In  1707,  Mery  had  seen  Saint- Yves's  perform  extraction  in  a  case  similar  to 
that  in  which  Petit  operated  in  the  following  year,  and  to  which  Daviel  refers.  Mery 
was  led  from  the  success  of  Saint- Yves's  operation,  to  recommend  extraction  through 
the  cornea  as  a  mode  of  removing  cataract  worthy  of  being  generally  adopted,  remark- 
ing "  qu  'on  risque  moins  a  tirer  la  cataracte  en  dehors  qu'  a  I'abattre  au  dedans  de 
I'ceuil."  Memoires  de  1' Academie  Royale  des  Sciences,  Annee  1707,  p.  606.  Am- 
sterdam, 1746. — Extraction  is  not  a  modern  invention.  Antyllus  appears  to  have 
practised  it  about  the  end  of  the  first  century;  as  also  Lathyrion  at  a  later  period. 
Haly- Abbas,  in  the  tenth  century,  describes  extraction  as  minutely  as  he  does  the 
operation  of  couching.  Histoire  de  la  Medecine  par  Sprengel,  traduite  paf  Jourdan. 
Tome  vii.  pp.  40,  41.    Paris,  1815. 


512 

1st  Period.  In  opening  the  cornea,  care  must  be  taken  that 
the  section  be  made  of  sufficient  size,  of  a  proper  form,  and  at  a 
specified  and  regular  distance  from  the  sclerotica.  It  must  be  of 
sufficient  size  to  allow  the  exit  of  the  lens  without  hindrance,  and 
without  the  use  of  much  pressure  on  the  eye ;  and  to  admit  of  this, 
the  incision  will  require  to  extend  to  at  least  a  half  of  the  circum- 
ference of  the  cornea.  Mr.  Ware  supposes  the  whole  circumference 
of  the  cornea  to  be  divided  into  sixteen  equal  parts,  and  states  that 
nine  of  these  should  be  included  in  the  incision.  It  must  be  of  a 
proper  form,  not  angular,  nor  indented,  but  regular,  smooth,  and 
parallel  to  the  edge  of  the  sclerotica,  that  it  may  heal,  if  possible, 
by  the  first  intention,  and  leave  no  cicatrice  to  impede  the  en- 
trance of  light  into  the  eye.  It  ought  not  to  be  close  to  the  sclero- 
tica, for  then  the  iris  is  left  unsupported  and  is  apt  to  protrude  ;  neither 
ought  it  to  be  far  from  the  sclerotica  for  then  the  incision  will  be 
too  small,  and  the  cicatrice  which  may  follow,  will  impede  the  light 
in  its  passage  towards  the  pupil.  A  rim  of  cornea  of  at  least  the 
twentieth  of  an  inch  in  breadth,  should  be  left  between  the  sclerotica 
and  the  incision. 

The  inferior  half  of  the  circumference  of  the  cornea  has  gener- 
ally been  chosen  for  the  incision ;  some,  however,  have  preferred 
the  upper  half,  while  others,  entering  the  knife  on  the  temporal 
side,  and  above  the  equator  of  the  cornea,  have  brought  it  out  below 
the  equator  on  the  nasal  side,  and  thus  effected  a  section  of  the 
usual  crescentic  form,  half  on  the  temporal  and  half  on  the  lower 
side  of  the  cornea.  The  incision  of  the  lower  half  of  the  cornea 
is  the  most  easily  executed  ;  and  through  such  an  incision,  the 
opening  of  the  capsule  and  the  exit  of  the  lens,  are  accomplished 
with  the  least  difficulty.  But  if  this  incision  does  not  heal  by  the 
first  intention,  if  it  be  prevented  from  healing  by  a  protruding  iris, 
or  by  the  edge  of  the  lower  eyelid  intruding  into  the  wound,  then 
a  broad  unsightly  cicatrice  will  remain,  very  much  impeding  vision 
when  the  patient  looks  downwards,  or  even  altogether  preventing 
it.  From  this  last  objection,  the  incision  at  the  upper  edge  of  the 
cornea  is  entirely  exempt ;  for  even  supposing  that  it  heals  only 
after  suppuration,  and  that  in  consequence  of  protrusion  of  the  iris 
through  the  incision,  the  pupil  has  been  dragged  very  much  up- 
wards, or  is  even  entirely  closed  or  hid  behind  the  cicatrice,  still  the 
lower  part  or  the  cornea  (the  most  valuable  part)  will  be  left  perfect, 
and  b}^  opening  up  an  artificial  pupil,  vision  may  still  be  restored. 
Through  the  incision  at  the  upper  part  of  the  cornea,  however,  it  is 
much  more  difficult  to  effect  division  of  the  capsule,  and  to  conduct 
with  the  necessary  caution,  the  abstraction  of  the  lens.  The  half- 
lateral  half-inferior  incision,  when  the  degree  of  prominence  of  the 
external  angular  process  of  the  frontal  bone  is  such  as  will  permit 
the  application  of  the  knife  in  the  obhque  direction,  is  perhaps  the 
best ;  exposing  less  the  lips  of  the  wound  to  be  disturbed  by  pro- 
trusion of  the  iris,  or  by  intrusion  of  the  edge  of  the  lower  lid,  than 


513 

the  incision  of  the  lower  half  of  the  cornea,  and  more  readily  per- 
mitting the  division  of  the  capsule  and  safe  exit  of  the  lens,  than 
the  incision  at  the  upper  edge. 

Various  forms  have  been  given  to  the  cornea-knife,  but  on  the 
whole,  the  best  is  that  which  is  now  generally  known  as  Professor 
Beer's.  The  cutting  edge  of  this  instrument  is  placed  at  an  angle 
of  17"  with  the  back,  wliich  is  continued  in  a  straight  line  from  the 
handle.  The  point  is  double-edged  for  the  length  of  a  Une,  the 
strength  and  temper  of  the  instrument  such  that  it  is  unbending, 
and  it  gradually  increases  in  thickness  as  it  does  in  breadth. 

The  fingers  of  the  assistant  and  operator  are  to  be  applied,  as  has 
been  directed  at  page  497,  and  especial  care  is  to  be  taken,  that  the 
operator's  middle  finger  is  so  placed  on  the  caruncula  lachrymalis, 
that  the  eye  about  to  be  cut  shall  be  prevented  from  turning  towards 
the  nose,  a  position  which,  if,  by  inattention  to  the  rule  here  laid 
down,  the  operator  permits,  he  may  find  it  impossible  to  complete 
the  section  which  he  has  commenced.  This  is  one  of  the  most 
important  cautions  in  the  whole  operation. 

I  shall  suppose  that  the  operator  is  about  to  open  the  lower  half 
of  the  cornea.  In  doing  this,  he  will  require  to  observe  the  follow- 
ing rules. 

1.  The  point  of  the  knife  is  to  be  entered  on  the  temporal  side 
of  the  cornea,  at  the  distance  of  l-20th  of  an  inch  from  the  sclero- 
tica, and  l-20th  of  an  inch  above  the  horizontal  diameter  of  the 
cornea. 

2.  The  instrument  is  to  be  directed  at  first  perpendicularly  to  the 
lamellae  of  the  cornea,  as  if  it  were  intended  to  penetrate  into  the 
iris,  in  order  that  the  lamellae  may  be  fairly  punctured,  and  the  point 
of  the  knife  arrive  in  the  anterior  chamber.  If  this  rule  is  neglect- 
ed, and  the  instrument  be  introduced  into  the  cornea  in  a  direction 
parallel  to  the  plane  of  the  iris,  it  may  easily  slip  between  the  lam- 
ellae, and  not  enter  the  anterior  chamber  at  all. 

3.  As  soon  as  the  point  of  the  knife  has  penetrated  into  the  an- 
terior chamber,  or,  in  other  words,  as  soon  as  the  'punctuation  of 
the  cornea  is  performed,  the  handle  of  the  instrument  is  to  be  car- 
ried back  towards  the  temple,  and  the  extremity  of  the  blade  di- 
rected towards  the  point  of  exit  on  the  nasal  side  of  the  cornea. 
Fixing  his  eye  on  this  point,  which  ought  to  be  rather  a  little  above 
than  below  the  horizontal  diameter  of  the  cornea,  and  at  the  same 
distance  from  the  sclerotica  as  the  point  of  entrance,  the  operator 
carries  the  instrument  cautiously  and  steadily  towards  it,  neither  too 
quickly  nor  too  slowly,  and  turning  the  edge  of  the  knife  neither 
forwards  nor  backwards,  but  keeping  it  perfectly  parallel  to  the  iris. 
In  traversing  thus  the  anterior  chamber,  let  the  operator  bend  his 
eye  on  nothing  but  the  point  of  counter-punctuation  ;  if  he  do  so, 
the  point  of  the  knife  will  be  sure  to  follow,  whereas,  if  he  allow 
himself  to  be  diverted  to  any  thing  else,  for  instance,  to  what  the 
edge  of  the  knife  is  doing,  he  may  miss  his  aim,  and  bring  out  the 

65 


514 

instrument  at  a  wrong  place.  Having  reached  the  point  of  exit,  he 
carries  the  knife  still  onwards  till  the  counter-punctuation  is  effected. 
He  has  now  the  eye  completely  under  his  control.  The  middle  fin- 
ger, which  it  was  so  important  should  rest  till  now  upon  the  carun- 
cula  lachrymalis,  and  prevent  the  eye  from  turning  inwards,  may 
be  shifted  to  the  lower  lid  ;  and,  if,  by  the  operator's  express  desire, 
the  assistant  has  been  making  pressure  on  the  upper  part  of  the  eye, 
that  pressure  must  be  discontinued. 

4.  The  counter-punctuation  being  effected,  the  section  of  the  cor- 
nea is  to  be  completed,  simply  by  the  progressive  motion  of  the 
knife  till  it  has  cut  itself  out.  In  this  part  of  the  operation,  no 
pressing  downwards  of  the  edge  of  the  knife  is  allowable,  much 
less  any  sawing  motion.  The  handle  of  the  instrument  is  to  be 
kept  well  back,  so  that  the  extremity  of  the  blade  may  avoid  touch- 
ing the  nose  as  it  advances.  When  the  incision  is  nearly  complet- 
ed, the  operator  cannot  proceed  too  cautiously.  If  the  aqueous  hu- 
mour has  been  entirely  retained  till  now,  the  knife  should  be  turn- 
ed a  little  on  its  axis,  so  as  to  allow  the  aqueous  humour  to  escape. 
If  this  is  neglected,  the  pressure  of  the  knife  upon  that  fluid,  acting 
on  the  lens  and  vitreous  humour,  is  apt  to  burst  the  hyaloid  mem- 
brane, particularly  if  this  membrane  is  weak,  as  it  often  is  in  old 
age,  and  thus  give  rise  to  ejection  of  the  vitreous  humour.  The 
instant  that  the  section  is  finished,  the  upper  eyelid  is  allowed  to 
fall,  the  light  admitted  into  the  room  ought  to  be  moderated,  and 
the  patient  is  to  be  recommended  to  compose  himself,  and  to  be  as^ 
sured  that  the  worst  of  the  operation  is  over. 

These  same  rules  are  to  be  followed,  if  the  incision  is  made  up- 
wards or  laterally,  except  in  regard  to  the  points  of  entrance  and 
exit  of  the  knife. 

2d  Period.  Various  instruments  have  been  employed  for  open- 
ing or  destroying  the  anterior  hemisphere  of  the  capsule,  which  is 
the  object  of  the  second  period  of  this  operation.  Some  employ  a 
simple  needle,  like  a  common  sewing  needle,  fixed  in  a  handle,  its 
point  bent  with  a  gentle  sweep,  or  at  a  right  angle  ;  and  with  this, 
they  make  a  single  scratch  through  the  capsule,  in  general  quite 
sufficient  to  allow  the  exit  of  the  lens.  Others  employ  a  lance- 
shaped  straight  needle,  the  lance-shaped  part  being  broader  and 
shorter  than  that  of  the  needle  for  depression.  The  edges  of  this 
instrument  are  sharp,  and  one  of  them  being  turned  against  the 
capsule,  this  membrane  is  divided  by  several  obUque  incisions  run- 
ning frora  right  to  left,  and  crossed  by  as  many  running  from  left 
to  right,  so  that  the  capsule  is  reduced  to  a  number  of  small  lozenge- 
shaped  portions,  some  of  which  probably  come  away  with  the  lens, 
but  which,  if  left  in  the  eye,  cannot  again  unite  to  form  a  capsular 
cataract.  The  latter  is  the  more  satisfactory,  the  former  the  easier 
mode  of  opening  the  capsule. 

The  assistant  begins  the  second  period  of  the  operation,  by  very 
cautiously  raising  the  upper  lid,  but  does  not  bring  the  points  of 


515 

'  the  fingers  over  its  edge.  The  operator  draws  down  the  lower  lid, 
and  presses  it  gently  against  the  eyeball.  The  degree  of  pressure 
ought  to  be  such  as  shall  cause  the  cataract  to  advance  a  little,  and 
the  pupil  to  expand,  so  as  to  allow  of  the  more  complete  division  of 
the  capsule.  If  no  pressure  is  exercised,  the  capsule  may  escape 
being  opened  at  all.  If  too  much  is  employed,  the  hyaloid  mem- 
brane will  burst,  and  the  vitreous  humour  be  ejected. 

The  needle  is  now  introduced  under  the  loose  flap  of  the  cor- 
nea, as  far  as  the  pupil ;  the  point  or  cutting  edge  is  turned  to- 
wards the  capsule ;  the  division  of  that  membrane  is  effected,  as 
has  already  been  stated,  by  one  or  by  several  incisions ;  the  in- 
strument is  cautiously  withdrawn ;  and  the  lids  are  again  permit- 
ted to  close.  The  patient  ought  here  to  be  cautioned  not  to  squeeze 
the  lids  together,  but  merely  to  keep  them  shut,  as  if  he  were 
asleep, 

3rf  Period.  If  the  pressure  exercised  upon  the  lower  part  of 
the  eyeball,  during  the  second  period  of  the  operation,  were  con- 
tinued, the  lens  would  be  observed  immediately  to  follow  the  with- 
drawal of  the  needle  with  which  the  capsule  was  divided.  The 
experienced  operator  may  run  in  this  way  the  second  and  third 
periods  together,  but  those  who  have  not  operated  frequently,  will 
find  it  advantageous  to  pause  for  a  few  minutes  before  proceeding 
to  the  third  period. 

It  is  usual  to  have  the  curette,  scoop,  or  as  it  is  sometimes  called 
Daviel's  spoon,  attached  to  the  opposite  extremity  of  the  same  han- 
dle in  which  is  fixed  the  needle  for  opening  the  capsule.  Holding, 
then,  the  curette  in  the  hand  which  formerly  held  th€  knife  and 
the  needle,  while  the  assistant  raises  the  upper  lid  as  before,  the 
operator  depresses  the  lower  lid  and  renews  the  degree  of  pressure 
formerly  exercised  through  the  medium  of  the  lid  on  the  lower 
part  of  the  eyeball.  The  pupil  is  seen  to  dilate,  the  inferior  edge 
of  the  lens  advances  through  the  pupil,  the  whole  lens  passes  into 
the  anterior  chamber,  and  makes  its  exit  through  the  incision  of 
the  cornea,  without  any  other  interference,  in  general,  or  any  other 
means  of  extraction  being  employed,  than  a  continuance  of  mode- 
rate pressure  on  the  lower  part  of  the  eyeball.  The  curette  is  used 
to  assist  the  extraction  only  if  the  lens  appears  to  be  arrested  be- 
tween the  lips  of  the  incision  of  the  cornea,  or  if  it  appears  to  be 
falling  in  pieces. 

The  patient  should  now  be  desired  again  to  close  his  eyes  as 
if  he  were  asleep,  while  the  operator,  having  received  the  lens  on 
his  finger  nail,  examines  whether  it  is  entire. 

When  the  patient  has  recovered  a  little  from  the  confusion  aris- 
ing from  the  admission  of  light  into  the  eye,  he  may  turn  himself 
round  on  his  chair,  so  that  his  back  shall  be  towards  the  window. 
The  eye  which  has  not  been  operated  on,  may  now  be  covered 
with  a  light  compress  and  roller  ;  and  the  surgeon,  holding  up  his 
hand  at  the  distance  of  about  18  inches  from  the  patient's  face, 


516 

may  desire  him  to  look  with  the  eye  whence  the  cataract  has  been 
removed,  and  to  say  whether  he  sees  any  thing.  It  were  better, 
in  some  respects,  to  dispense  with  all  this ;  but  the  patient  who 
submits  to  extraction,  knows  that  such  experiments  are  made  and 
expects  them,  and  if  put  to  bed  without  having  ascertained  what 
degree  of  vision  he  is  likely  to  recover  by  the  operation,  is  apt  to 
get  anxious,  and  to  make  trials  of  his  own,  which  may  be  much 
more  detrimental. 

The  patient  is  now  to  turn  round  again  towards  the  light.  The 
operator  with  his  thumb  repeatedly  and  gently  rubs  the  upper  eye- 
lid over  the  surface  of  the  eyeball,  raises  the  lid,  and  rapidly  ex- 
amines the  appearance  of  the  pupil  and  the  state  of  the  flap  of  the 
cornea.  If  the  pupil  is  circular  and  clear,  and  the  edges  of  the  in- 
cision of  the  cornea  accurately  in  contact,  he  desires  the  patient  to 
look  upwards,  and  then  immediately  to  close  his  eyes,  informing 
him  at  the  same  time,  that  he  is  not  to  make  any  farther  attempt 
to  open  them  for  four  and  twenty  hours,  but  to  keep  them  closed, 
without  squeezing  the  lids  together,  and  in  fact,  exactly  as  if  he 
were  asleep.  A  strip  of  court-plaster,  about  an  inch  long  and  the 
fifth  of  an  inch  broad,  is  now  to  be  applied  from  the  middle  of  the 
upper  lid  to  the  middle  of  the  lower,  both  over  the  eye  v/hich  has 
been  operated  on,  and  over  the  other.  A  hght  roller  with  a  fold  of 
linen  attached  to  it  is  put  round  the  head,  the  fold  hanging  down 
over  the  eyes. 

Modifications  of  extraction  according  to  varieties  of  cataract, 
and  peculiar  states  of  the  eye.  1.  If  the  eye  to  be  operated 
on  is  more  than  ordinarily  prominent,  the  incision  ought  not  to  be 
mad©  at  the  lower  edge  of  the  cornea,  lest  the  lower  lid  should  in- 
trude into  the  wound,  and  prevent  it  from  healing  by  the  first  in- 
tention. The  incision  should  be  either  at  the  temporal  or  the  up- 
per edge  of  the  cornea. 

2.  It  sometimes  happens  that  the  cornea  is  not  only  remarkably 
flat,  but  that  the  iris  appears  to  project  forward  in  the  anterior 
chamber,  forming  a  convex  instead  of  a  plane  surface.  In  cases 
of  this  description,  the  anterior  chamber  is  so  small,  that  if  an  at- 
tempt be  made  to  complete  the  division  of  the  cornea  by  one  semi- 
circular incision,  it  will  be  found  extremely  difficult,  if  not  impossi- 
ble, to  carry  the  point  of  the  knife  from  the  temporal  to  the  nasal 
edge  of  the  cornea,  without  wounding  the  iris.  Under  such  cir- 
cumstances, therefore,  it  is  ad\dsable  to  include  only  one-third  of  the 
cornea  in  the  first  incision,  and  afterwards  to  enlarge  the  aperture 
by  means  of  DavieFs  scissors. 

3.  In  cases  of  floating  cataract,  such  as  the  cystic,  of  capsular 
cataract,  and  of  cataract  combined  with  dissolved  vitreous  humour, 
it  is  not  necessary,  and  often  not  safe,  to  extend  the  incision  to  a 
semicircle.  It  will  be  sufficient,  under  such  circumstances,  to  divide 
one-third  of  the  circumference  of  the  cornea,  and  through  this  small 
incision  to  extract  with  the  assistance  of  a  hook,  as  I  shall  hereafter 
explain  at  greater  length. 


517 

4.  In  cases  of  capsulo-lenticular  cataract ,  it  is  proper  to  attempt 
the  extraction  of  the  capsule  as  well  as  of  the  lens.  Some  do  this 
before,  others  after  the  lens  is  removed.  The  cornea  being  divided 
in  the  usual  way,  a  needle  may  be  introduced,  a  little  bent  towards 
the  point,  with  which  we  may  attempt  to  divide  the  capsule  in  a 
circular  direction,  as  near  the  edge  of  the  pupil  as  the  instrument 
can  be  applied  without  injuring  the  iris.  The  part  included  with- 
in the  circular  division  may  sometimes  be  brought  away  on  the 
point  of  the  needle ;  but  if  this  cannot  be  done,  it  should  be  ex- 
tracted by  means  of  a  pair  of  small  forceps,  and  then  the  lens  is  to 
be  removed  as  in  ordinary  cases.  This  is  the  mode  recommended 
by  Mr.  Ware.  Beer,  on  the  other  hand,  first  extracted  the  lens, 
and  then  attempted  to  remove  the  shreds  of  the  opaque  capsule,  by 
means  of  a  delicate  pair  of  forceps,  the  one  blade  terminating  in  a 
a  tooth,  and  the  other  in  a  notch  which  receives  that  tooth.  This 
instrument  is  to  be  introduced  through  the  incision  of  the  cornea 
and  through  the  pupil,  opened  so  as  to  receive  one  of  the  shreds, 
and  shut  so  as  to  hold  it  without  any  possibility  of  its  escaping. 
Then  with  a  sudden  twitch,  the  shred  is  to  be  extracted  ;  and  this 
is  to  be  repeated  till  the  whole  are  removed. 

5.  We  sometimes  know  from  the  history  of  the  case,  that  the 
posterior  hemisphere  of  the  capsule  is  opaque  ;  or  immediately  after 
the  lens  is  removed,  we  observe  that  there  still  remains  an  opacity 
impeding  vision.  If  we  are  satisfied  that  this  opacity  consists  neither 
in  opaque  shreds  of  the  anterior  half  of  the  capsule,  nor  in  some 
portion  of  the  soft  exterior  substance  of  the  lens  retained  (as  it 
sometimes  is)  in  the  eye,  then  we  may  conclude  that  it  is  the  pos- 
terior hemisphere  of  the  capsule  in  the  cataractous  state.  Perhaps 
the  better  plan  in  such  a  case,  would  be  to  allow  the  eye  to  recover 
from  what  has  already  been  done,  and  by  a  subsequent  operation 
with  the  needle,  to  endeavour  to  remove  the  opaque  membrane 
out  of  the  axis  of  vision.  Some,  however,  have  recommended 
that  we  should  immediately  proceed  to  destroy,  and  if  possible,  to 
remove  the  posterior  half  of  the  capsule.  This  they  have  attempted 
by  means  of  a  needle,  of  which  one  of  the  edges  forms  a  hook  or 
barb,  so  that  it  enters  easily  through  the  membrane  in  question, 
and  being  then  turned  one  quarter  round  on  its  axis  and  suddenly 
withdrawn,  brings  along  with  it  a  portion  of  the  diseased  capsule. 
This  manipulation  is  to  be  repeated,  till  at  least  a  considerable  aper- 
ture is  formed  for  the  transmission  of  light  into  the  deeper  parts  of 
the  eye,  an  object  which  will  scarcely  ever  be  effected  without  some 
loss  of  vitreous  humour. 

Accidents  during  or  after  extraction.  1.  The  spirting  out  of 
the  aqueous  humour  before  the  counter-punctuation  of  the  cornea 
is  effected,  is  one  of  the  most  common  accidents  during  the  first 
period  of  extraction.  The  iris,  in  consequence  of  losing  its  usual 
support,  immediately  falls  forward,  and  getting  under  the  edge  of 
the  knife,  will  be  cut  across,  if  the  section  is  pursued  without  push- 


518 

ing  back  the  iris  into  its  place.  This  must  be  attempted  by  press- 
ing with  the  point  of  the  foie-finger  on  the  cornea.  If  in  conse- 
quence of  this  pressure,  the  iris  retires,  the  knife  is  to  be  carried 
quickly  across  the  anterior  chamber,  and  the  counter-punctuation 
effected.  This  once  accomphshed,  there  is  no  farther  danger  of 
the  iris  falling  under  the  edge  of  the  knife,  and  the  section  is  to  be 
completed  in  the  ordinary  way.  But  if  the  iris  does  not  retire  on 
pressure  of  the  cornea,  the  knife  must  be  withdrawn,  and  either  the 
operation  deferred  till  a  future  day,  or  a  small  probe-pointed  knife 
introduced  through  the  aperture  which  has  been  made,  pushed 
gently  through  the  anterior  chamber  to  the  nasal  edge  of  the  cor- 
nea, and  over  the  end  of  it  an  opening  made  with  another  knife  so 
as  to  allow  it  to  come  through,  after  which  the  incision  is  to  be  fin- 
ished exactly  in  the  same  way  as  if  the  sharp-pointed  knife  only 
had  been  employed. 

2.  When  the  point  of  the  knife  reaches  the  nasal  edge  of  the 
cornea,  the  operator  occasionally  finds  it  difficult  to  bring  it  through, 
in  which  case  he  may  derive  advantage  from  pressing  the  cornea 
against  the  knife  with  his  finger-nail.  In  other  instances,  the 
point  of  the  knife  is  seen  to  bend  to  one  side,  so  that  it  is  impossi- 
ble to  perform  the  counter-punctuation  in  the  ordinary  way. 
When  this  is  the  case,  the  knife  may  be  withdrawn  aad  the  opera- 
tion postponed,  or  what  is  preferable,  the  cornea  may  be  opened  on 
the  nasal  side  with  another  knife,  and  then  the  knife,  which  is 
already  across  the  anterior  chamber  may  be  carried  through  this 
opening,  and  the  section  completed. 

3.  Too  small  a  section  of  the  cornea  is  a  very  frequent  occur- 
rence, in  consequence  of  the  operator  bringing  out  the  knife  at  too 
great  a  distance  from  the  nasal  edge,  and  perhaps  considerably 
below  the  equator  of  the  cornea.  In  this  case,  the  incision  must 
be  enlarged  to  a  semicircle,  by  the  aid  of  Daviel's  scissors,  which 
are  so  bent  that  the  one  pair  serves  for  dividing  the  temporal  side 
of  the  right  eye  and  nasal  side  of  the  left,  and  the  other  pair  for  the 
temporal  side  of  the  left  and  nasal  side  of  the  right.  Rarely  will 
the  incision  require  to  be  enlarged  at  both  extremities  ;  but  upon  no 
account  is  the  operator  to  proceed  to  the  second  and  third  periods 
of  extraction,  if  he  is  conscious  that  the  section  of  the  cornea  is  less 
than  a  semicircle.  Loss  of  vitreous  humour,  severe  pressure  upon 
the  iris,  and  destructive  inflammation,  are  the  consequences  to  be 
dreaded  froni  forcing  a  large  cataract  through  a  small  incision. 
Resting  the  scissors  on  the  back  of  the  finger  which  depresses  the 
lower  eyelid,  and  opening  them  a  little,  the  one  blade  is  to  be  passed 
under  the  middle  of  the  flap  of  the  cornea  into  the  anterior  cham- 
ber, the  other  remaining  external  to  the  cornea  ;  the  instrument  is 
then  to  be  carried  close  to  the  temporal  or  nasal  edge  of  the  cor- 
nea, according  to  circumstances,  and  with  a  single  stroke,  the  in- 
cision is  to  be  enlarged  to  the  requisite  dimensions. 

4.  When  the  operator,  proceeding  to  the  third  period  of  extrac- 


519 

tion,  makes  pressure  on  the  lower  part  of  the  eyeball,  but  observes 
that  notwithstanding  this,  the  cataract  does  not  advance  through 
the  expanding  pupil,  he  ought  to  desist,  and  ask  himself  whether 
the  section  of  the  cornea  be  of  the  proper  size,  and  whether  he 
has  reason  to  think  that  he  has  in  a  sufficient  manner  opened  the 
capsule.  If  the  answer  in  the  affirmative  is  well  founded,  then 
merely  by  waiting  a  few  minutes,  directing  the  patient  to  turn  his 
eye  upwards  two  or  three  times,  rubbing  the  eye  gently  through 
the  medium  of  the  upper  lid,  moderating  the  light  still  more  than 
has  been  done,  and  then  repeating  the  pressure  on  the  lower  part 
of  the  eyeball,  the  lens  will  probably  advance,  and  make  its  exit  in 
the  usual  way.  But  if  the  smallness  of  the  section  be  the  cause  of 
the  cataract  not  coming  forward,  the  section  must  be  enlarged ;  or 
if  the  capsule  has  been  imperfectly  divided,  the  second  period  of  the 
operation  must  be  carefully  repeated.  Pressure  is  then  to  be  em- 
ployed on  the  lower  part  of  the  eyeball,  when,  in  general,  the  cat- 
aract will  advance.  The  pressure  must  be  at  once  moderate  and 
sufficient.  If  it  is  too  forcible,  the  hyaloid  membrane  is  very  apt 
to  burst,  and  the  vitreous  humour  to  be  ejected  before  the  lens.  If 
insufficient,  or  if  too  soon  relaxed  from  timidity  on  the  part  of  the 
operator,  the  lens  may  not  advance,  and  he  will  distress  himself 
with  imaginary  difficulties.  Yet  it  sometimes  happens  that  the 
section  of  the  cornea  is  sufficient,  the  capsule  sufficiently  opened, 
and  due  pressure  made,  without  the  lens  advancing.  This  arises 
from  an  unnatural  adhesion  between  the  lens  and  the  capsule,  and 
is  to  be  remedied  in  the  following  manner.  The  operator  is  to 
continue  the  pressure  till  the  lower  edge  of  the  lens  appears  in 
view,  he  is  then  to  introduce  a  thin  sharp  curette  through  the  pu- 
pil, under  and  behind  the  lens,  and  by  the  motion  of  this  instru- 
ment from  right  to  left,  to  separate  the  capsule  witli  the  lens  en- 
closed, from  the  hyaloid  membrane.  A  hook  is  then  to  be  intro- 
duced, and  the  lens  and  capsule  extracted.  This  will  scarcely  be 
effected  without  some  discharge  of  vitreous  humour,  but  certainly 
less  risk  attends  this  mode  of  procedure  than  that  of  forcing  out  the 
cataract,  under  such  circumstances,  by  continued  pressure. 

5.  It  sometimes  happens  from  the  lens  falling  in  pieces  at  the 
moment  of  extraction,  that  part  of  it  remains  behind  the  pupil. 
In  this  case,  if  the  operator  rubs  the  eye  gently  through  the  medi- 
um of  the  upper  lid,  and  then  opens  the  eye,  he  will  generally  find 
that  the  fragments  have  advanced  into  the  anterior  chamber. 
They  will  readily  escape  on  lifting  the  flap  of  the  cornea  with  the 
curette.  Any  small  particles  which  may  be  left  will  dissolve  in 
the  aqueous  humour. 

6.  An  escape  of  vitreous  humour  may  take  place  before,  along 
with,  or  after  the  exit  of  the  lens.  This  accident  is  sometimes  at- 
tributable to  immoderate  pressure  on  the  eye,  or  to  spasm  of  the 
recti,  or  orbicularis  palpebrarum,  but  much  more  frequently  it  is 
the  result  of  weakness  of  the  hyaloid  membrane  from  age  or  from 


520 

disease.  If  the  escape  of  vitreous  humour  commences  before  the 
lens  has  been  removed,  no  farther  pressure  must  be  made  on  the 
eye,  but  a  small  hook  is  to  l^e  introduced  so  as  to  lay  hold  of  the 
cataract,  which  is  to  be  withdrawn  as  speedily  as  possible.  The 
eye  is  then  to  be  shut,  and  very  gently  rubbed  through  the  medium 
of  the  upper  lid,  in  order  to  replace  the  iris,  which  is  very  apt, 
when  there  has  been  any  escape  of  vitreous  humour,  to  protrude 
through  the  wound  of  the  cornea.  The  cornea  heals  more  slowly 
than  usual  after  this  accident,  the  cicatrice  is  broader,  the  pupil  not 
unfrequently  distorted,  and  vision  less  perfect.  If  only  a  fifth  or 
even  a  fourth  of  the  vitreous  humour  is  lost,  vision  may  not  be 
very  materially  affected.  If  a  third  is  lost,  we  cannot  calculate  on 
any  very  useful  degree  of  vision.  If  more  than  a  third  is  evacuated, 
the  pupil  generally  closes,  and  the  eyeball  becomes  permanently 
atrophic. 

I  have  already  had  occasion  to  mention,  that  when  the  eye  is 
known  to  have  been  glaucomatous  before  becoming  affected  with 
cataract,  we  may  expect  to  meet  with  a  dissolved  state  of  the  hya- 
loid membrane.  If  we  operate  by  extraction  in  such  a  case,  and 
extend  our  incision  to  a  semicircle,  we  may  lay  our  account  with 
an  ejection  of  vitreous  humour. 

If  the  capsule  has  been  opened  in  a  previous  operation,  with  the 
view,  for  example,  of  softening  a  hard  cataract  previously  to  at- 
tempting to  divide  it,  or  if  displacement  has  been  ineffectually  per- 
formed, and  the  operator  proceeds  to  extraction,  he  will  almost  to  a 
certainty  encounter  a  dissolved  hyaloid  membrane,  and  of  course  an 
evacuation  of  vitreous  humour. 

7.  Immediately  after  the  lens  has  escaped  from  the  e)'^e,  ihe  iris 
is  apt  to  protrude  through  the  wound  of  the  cornea.  This  is  in 
general  very  easily  remedied,  merely  by  rubbing  the  eye  for  a  lit- 
tle through  the  mediuixi  of  the  upper  lid,  and  then  suddenly  ex- 
posing the  eye  to  the  hght.  Should  this  not  succeed,  we  may  en- 
deavour to  press  the  iris  into  its  place  with  the  curette  ;  and  should 
this  also  fail,  a  small  snip  may  be  made  in  the  protruding  por- 
tion of  iris,  when  it  will  often  return  almost  of  itself  into  the  eye, 
in  consequence  of  the  aqueous  humour  which  was  lodged  behind 
it  draining  away. 

It  is  very  different  \vith  a  protrusion  of  the  iris  which  is  apt  to 
take  place  about  the  fourth  day  after  the  operation,  and  which, 
though  commonly  attributed  to  some  accidental  blow  upon  the  eye, 
restlessness  on  the  part  of  the  patient,  or  improper  attempts  which 
he  may  have  made  to  use  the  eye,  is,  I  am  convinced,  to  be  as- 
cribed rather  to  the  supervention  of  undue  inflammation  of  the  cor- 
nea, and  of  inflammation  within  the  eye,  than  to  any  mere  me- 
chanical cause.  I  do  not  deny,  however,  that  this  accident  is 
favoured  by  making  the  incision  too  close  to  the  sclerotica.  This 
protrusion  does  not  take  place  suddenly.  We  first  of  all  observe 
the  wound  gaping  a  little,  and  its  edges  white,  swollen,  and  everted. 


521 

Next  the  iris  begins  to  show  itself  between  the  hps  of  the  wound, 
and  as  the  aqueous  humour  accumulates  behind  it,  this  staphyloma 
iridis  increases.  At  the  same  time,  the  protruding  portion  of  the 
iris  inflames,  and  is  united  by  effused  lymph  to  the  edges  of  the 
wound  of  the  cornea.  The  conjunctiva  and  sclerotica  redden,  the 
discharge  of  tears  is  frequent  and  irritating,  the  patient  feels  as  if 
some  foreign  substance  of  considerable  bulk  were  lodged  beneath 
the  eyelids,  the  eye  and  supra-orbital  region  become  painful,  the 
skin  dry  and  hot,  and  the  pulse  quick.  No  direct  attempt  need  be 
made  to  reduce  this  protrusion.  Snipping  it  wit.h  the  scissors, 
however,  can  do  no  harm.  A  vein  of  the  arm  ought  to  be  opened 
once,  and  again,  if  necessary  ;  leeches  are  to  be  applied  liberally 
round  the  eye,  and  a  blister  behind  the  ear.  The  bowels  should 
be  acted  on  by  a  brisk  purgative,  and  calomel  with  opium  admin- 
istered till  the  mouth  is  affected.  These  are  the  most  likely  means 
to  abate  the  inflammatory  action  upon  which  the  protrusion  appears 
to  depend.  Belladonna  is  to  be  avoided,  as  rather  tending  to  fa- 
vour the  protrusion.  Indeed  the  fear  of  this  accident  is  one  of  the 
principal  causes  why  we  refrain  from  the  use  of  belladonna  in  ex- 
traction. From  day  to  day,  the  protruding  iris  may  be  touched 
with  a  sharpened  pencil  of  lunar  caustic. 

A  broad  cicatrice  of  the  cornea,  with  a  dragging  of  the  pupil 
towards  the  cicatrice,  is  the  necessary  consequence  of  this  accident, 
even  when  the  most  appropriate  means  of  cure  are  had  recourse  to. 
If  neglected,  the  pupil  may  be  so  much  distorted  as  to  be  completely 
hid  behind  the  cicatrice,  with  the  upper  half  of  the  iris  very  much 
on  the  stretch,  a  state  of  matters  which  still  affords  a  tolerable 
chance  of  vision  being  restored  by  the  formation  of  an  artificial 
pupil.  In  still  more  unfortunate  cases,  the  inflammation  is  so  se- 
vere and  extensive,  and  is  prolonged  for  such  a  length  of  time,  be- 
fore the  prolapsed  portion  of  the  iris  shrinks  and  the  cornea  unites, 
that  the  vessels  of  the  eye  are  left  varicose  and  the  retina  insensible. 

8.  It  sometimes  happens,  perhaps  in  consequence  of  carelessness 
in  adjusting  the  flap  of  the  cornea,  that  the  edges  of  the  wound 
unite  in  so  imperfect  a  manner,  as  to  be  unable  to  withstand  the 
pressure  of  the  aqueous  humour.  The  consequence  is,  that  there 
is  protruded  from  between  the  lips  of  the  wound  a  thin  semi-trans- 
parent membrane,  having  the  form  of  a  vesicle,  distended  by  aque- 
ous humour,  and  giving  rise  to  the  sensation  of  a  foreign  body  in 
the  eye.  If  this  membrane,  which  has  genei'ally  been  regarded  as 
the  lining  membrane  of  the  cornea,  be  punctured,  the  tumour  formed 
by  it  subsides ;  but  speedily  reuniting,  it  is  protruded  as  before,  so 
that  it  is  better  to  snip  it  off  close  to  the  original  edges  of  the  wound, 
and  keeping  the  eye  shut  for  several  days,  endeavour  thus  to  pro- 
cure a  more  perfect  union.  The  cicatrice  in  every  such  case  will 
be  very  considerable. 

9.  Inflammation  is  the  consequence  most  to  be  dreaded  after  the 
operation  of  extraction.     It  attacks  one  or  several  of  the  textures  of 

66 


522 

the  eye,  occurs  with  very  various  degress  of  severity,  and  comes  on 
at  different  periods  of  time  after  the  operation.  The  conjunctiva  is 
frequently  its  seat,  and  then  it  presents  the  symptoms  of  puro-mu- 
coLis  ophthahnia  ;  the  eye  feels  as  if  tilled  with  sand ;  there  is  con- 
siderable chemosis  with  puriform  discharge,  and  adhesion  of  the 
lids.  In  other  cases,  the  cornea  inflames  more  than  is  consistent 
with  the  healing  of  the  wound  by  the  first  intention  ;  the  lips 
of  the  incision  gape,  the  iris  is  apt  to  protrude,  and  a  broad  un- 
sightly cicatrice  is  the  result.  In  many  instances  the  sclerotica 
and  iris  inflame ;  the  patient  is  affected  with  severe  pulsative  pain 
in  and  round  the  eye,  aggravated  during  the  night,  followed  by 
effusion  of  lymph  from  the  iris,  opacity  of  the  shreds  of  the  capsule, 
and  it  may  be  by  closure  of  the  pupil.  In  other  cases,  and  es- 
pecially where  the  flap  of  the  cornea  has  been  often  lifted,  and 
numerous  instruments  introduced  into  the  interior  of  the  eye,  the 
inflammation,  although  internal,  does  not  partake  so  much  of  the 
adhesive  as  of  the  suppurative  character  ;  so  that  the  organ  is  in 
still  greater  danger  of  being  destroyed.  That  pecuhar  inflammation, 
call  by  the  Germans  arthritic,  and  which,  whatever  be  its  nature, 
is  undoubtedly  a  specific  inflammation,  is  also  extremely  apt  to  be 
excited  by  the  operation  of  extraction. 

It  very  rarely  happens  that  this  operation  is  not  followed  by  such 
a  degree  of  inflammation  in  one  or  other  of  the  textures  of  the  eye, 
as  to  require  the  abstraction  of  blood  from  the  system.  So  well 
established  is  this  observation,  that  some  make  it  a  general  rule  to 
bleed  the  patient  at  the  arm,  in  the  course  of  the  first  twenty-four 
hours  after  the  operation,  whether  pain  is  complained  of  or  not. 
The  quantity  of  blood  to  be  removed,  and  the  frequency  with 
which  venesection  is  to  be  repeated,  will  of  course  be  regulated  by 
the  age  and  constitution  of  the  patient,  and  the  nature  and  se- 
verity of  the  inflammation.  Puro-mucous  conjunctivitis  will  re- 
quire much  less  depletion  than  sclerotitis  or  iritis,  and  might  perhaps 
yield  to  local  remedies  alone ;  but  when  the  internal  textures  of  the 
eye  are  attacked,  copious  and  repeated  blood-letting  from  the  sys- 
tem will  be  necessary,  followed  by  leeches  to  the  temples,  the  use 
of  calomel  with  opium  internally,  and  the  application  of  blisters 
behind  the  ear  or  to  the  nape  of  the  neck.  Belladonna  is  a  doubt- 
ful remedy.  Where  closure  of  the  pupil  is  threatened,  it  is  hkely 
to  be  serviceable  ;  but  if  there  appears  to  be  any  tendency  to  pro- 
trusion of  the  iris  through  the  wound,  it  ought  to  be  avoided. 

After-treatment.  The  room  in  which  the  patient  is  to  sleep 
after  the  operation,  should  be  large  and  well  aired,  with  a  tempera- 
ture of  from  50°  to  55°,  and  free  from  cold  draughts.  The  patient 
ought  neither  to  be  loaded  with  unnecessary  bed-clothes,  nor  ex- 
posed to  cold  from  tTneir  deficiency.  He  may  lie  either  upon  his  back, 
or  on  the  side  opposite  to  that  of  the  eye  which  has  been  operated 
on.  He  should  be  put  to  bed  with  as  little  movement  of  the  head 
and  body  as  possible.     The  room  is  not  to  be  made  too  dark,  but 


523 

is  to  be  kept  perfectly  quiet,  in  order  to  avoid  all  causes  of  sudden 
alarm  or  starting.  All  unnecessary  talking  between  the  patient 
and  those  about  him  is  to  be  prevented.  A  careful  assistant  or  ex- 
perienced nurse,  sitting  constantly  by  the  bed-side  for  the  first  for- 
ty-eight hours  and  for  several  succeeding  nights,  ought  attentively 
to  watch  the  patient  when  he  wakes,  taking  care,  especially,  that 
he  does  not  turn  suddenly  round  upon  the  eye  which  has  been  cut, 
or  put  up  his  hand  to  rub  the  eye.  If  there  is  any  particular  reason 
to  dread  the  latter  accident,  it  may  be  proper  to  mufHe  the  patient's 
hands,  and  pin  them  down  by  his  sides. 

The  length  of  time  during  which  the  patient  is  to  be  kept  in 
bed,  is  a  point  upon  which  there  has  been  a  wide  diversity  of  prac- 
tice. It  would  appear  that  Wenzel  was  at  one  time  in  the  habit 
of  confining  his  patients  to  their  backs,  without  change  of  posture 
for  a  fortnight  or  three  weeks,  but  that  afterwards  he  shortened  the 
period  of  confinement  to  eight  or  ten  days.  Mr.  Phipps,  on  tlie 
other  hand,  examined  the  eyes  on  the  morning  after  the  operation, 
applied  a  shade,  and  allowed  the  patient  to  rise.*  A  middle  course 
appears  to  be  the  most  judicious.  The  incision  may  be  looked  at 
on  the  third  day.  On  the  fourth  day,  the  patient  may  be  allowed 
to  sit  up  for  a  short  time.  On  the  fifth,  the  eye  may  be  fairly  ex- 
amined, but  immediately  afterwards  covered  with  the  shade.  In 
eight  or  ten  days,  the  patient  may  be  allowed  to  look  at  large  ob- 
jects, and  to  walk  about  his  room. 

It  is  desirable  that  the  patient's  bowels  should  not  be  disturbed 
for  the  first  twenty-four  or  even  forty-eight  hours  after  the  opera- 
tion, as  the  movements  of  the  body  in  getting  out  of  bed,  and 
while  at  stool,  may  prove  injurious  to  the  eye.  After  forty-eight 
hours,  a  laxative  clyster  may  be  administered,  if  necessary.  A 
strict  antiphlogistic  plan  of  diet  is  to  be  observed  for  eight  days  or 
more,  according  to  circumstances ;  after  which,  soup  may  be  al- 
lowed, and  in  about  a  fortnight  after  the  operation,  a  little  animal 
food. 

The  aqueous  humour  generally  continues  to  be  discharged  from 
the  eye  for  about  40  hours  ;  in  some  cases,  however,  for  a  shorter 
period,  and  often  for  a  much  longer,  even  for  weeks.  Lest  the 
ready  discharge  of  the  aqueous  humour,  as  also  of  the  tears,  should 
be  prevented,  it  is  improper  to  cover  up  the  eye  closely,  and  still 
more  improper  to  load  it  with  unnecessary  dressings  and  bandages. 
Indeed,  if  the  edges  of  the  incision  appear  to  come  accurately  to- 
gether of  themselves  immediately  after  the  operation,  and  if  the 
patient  can  be  depended  on  to  keep  his  eyes  shut,  I  am  convinced 
that  it  is  better  to  employ  no  plaster,  dressing,  nor  covering  what- 
ever, except  a  simple  shade.  If  a  strip  of  court-plaster  is  apphed, 
it  is  to  be  removed  after  twenty-four  hours,  and  either  the  eyes  left 

*  On  the  Treatment  of  Patients  after  the  Operation  for  the  Cataract ;  by  Jonathan 
Wathen  Phipps ;  published  as  an  Appendix  to  Wathen  on  Fistula  Lachrymalis. 
London,  1792. 


524 

uncovered,  or  the  strip  of  plaster  replaced  by  a  small  piece  of  linen 
spread  with  simple  cerate.  Each  time  the  dressings  are  changed, 
the  lower  lid  should  be  drawn  a  little  downwards,  to  allow  any- 
fluid  accumulated  behind  the  lids  to  escape.  Bathing  the  lids 
should  not  be  attempted  for  three  or  four  days,  and  even  then  must 
be  done  with  great  caution,  and  only  by  the  surgeon. 

II.  Extraction  through  a  section  of  one-third  of  the  circum- 
ference of  the  Cornea. 

I  have  already  had  occasion  to  mention,  when  treating  of  the 
accidents  attendant  on  the  operations  of  displacement,  that  the  lens 
occasionally  passes  through  the  pupil,  and  lodges  between  the 
cornea  and  the  iris.  It  would  be  incorrect  to  say  that  when  in 
this  situation  it  was  in  the  anterior  chamber,  for  as  the  axis  of  the 
aqueous  humour  is  to  that  of  the  lens  as  3  to  4,  it  is  evident,  that 
after  it  has  passed  through  the  pupil,  the  lens  will  occupy  not  only 
the  anterior  chamber,  but  the  posterior  also,  and  even  part  of  the 
space  which  it  filled  while  in  its  natural  situation.  The  iris  con- 
sequently will  be  pressed  backwards  by  the  dislocated  lens,  and  it 
will  be  easy  to  lay  open  a  third  of  the  circumference  of  the  cornea, 
without  touching  the  iris.  A  hook  being  then  introduced,  the  lens 
is  to  be  laid  hold  hold  of,  and  extracted. 

This  mode,  then,  of  removing  a  lens  which  has  fallen  in  front 
of  the  iris,  has  led,  in  a  variety  of  other  cases,  to  the  practice  of 
opening  only  a  third,  or  less  than  a  third,  of  the  circumference  of 
the  cornea.  The  wound  in  this  way  being  less  extensive,  will  in 
general  heal  more  readily  ;  and  even  should  it  inflame  and  unite 
but  slowly,  will  leave  less  deformity,  and  produce  a  much  less  de- 
gree of  impediment  to  the  passage  of  light  into  the  eye,  than  the 
broad  semilunar  cicatrice,  which  is  apt  to  follow  the  common  ope- 
ration of  extraction.  The  lips  of  the  incision,  when  only  a  third 
of  the  circumference  of  the  cornea  is  opened,  will  close  much  more 
completely  immediately  after  the  operation  is  finished,  so  that  we 
need  not  be  afraid  of  prolapsus  of  the  iris,  and  may  therefore  dilate 
the  pupil  by  belladonna  before  proceeding  to  the  operation,  which 
will  both  enable  the  lens  to  be  more  easily  brought  forward  in  front 
of  the  iris,  and  render  injury  of  the  iris  less  hable  to  occur.  Through 
a  small  section,  also,  of  the  cornea,  especially  in  cases  of  dissolved 
hyaloid  membrane,  the  vitreous  humour  is  less  likely  to  be  evac- 
uated to  any  considerable  extent. 

Of  the  reality  of  some  of  these  advantages  I  am  able  to  speak 
decidedly,  as  I  have  employed  this  method  of  extraction  in  a  va- 
riety of  cases.  I  now  prefer  it,  when  it  is  my  object  to  extract  a 
capsular  cataract,  or  when  I  have  reason  to  believe  that  the  vitreous 
humour  is  dissolved. 

1.  The  following  is  the  plan  which  I  have  successfully  adopted 
in  cases  of  capsular  or  siliquose  cataract,  the  lens  having  either 
been  absorbed  in  consequence  of  an  accidental  wound  of  the  cap- 


525 

sule,  or  removed  by  a  previous  operation.  I  place  the  patient  in  the 
horizontal  position,  and  pass  a  small  curved  needle  through  the 
sclerotica,  with  which  I  endeavour  as  much  as  possible  to  gather 
together  the  opaque  capsule  into  a  mass,  which  1  then  push 
through  the  pupil.  The  needle  I  now  deliver  to  the  assistant,  who 
is  to  hold  it  steadily  in  the  same  position,  while  with  the  extrac- 
tion-knife^  or  a  broad  iris-knife,  I  open  one  side  of  the  cornea  (gen- 
erally the  temporal  side)  to  a  third,  or  nearly  a  third  of  its  extent. 
I  then  introduce  either  a  hook  or  a  small  pair  of  toothed  forceps, 
lay  hold  of  the  capsule,  and  either  immediately  extract  it,  or  if  I 
find  this  opposed  by  any  adhesion,  turn  the  instrument  round  on 
its  axis  till  the  membrane  is  detached.  In  one  case,  in  which  I 
found  the  capsule  so  strongly  adherent  to  the  iris,  that  I  was  afraid 
I  might  sooner  sever  the  latter  from  the  choroid  than  extract  the 
capsule,  I  contented  myself  with  prolapsing  the  capsule  through 
the  wound  of  the  cornea,  clearing  in  this  way  the  pupil,  and  re- 
storing a  very  useful  degree  of  vision.  Under  such  circumstances, 
the  iris-scissors  might  be  advantageously  employed  in  dividing  the 
half-detached  capsule. 

2.  Mr.  Gibson,  of  Manchester,  appears  to  have  been  the  first  to 
extract  soft  cataracts  through  a  small  incision  of  the  cornea.  He 
was  led  to  adopt  this  practice  from  the  great  length  of  time  which 
soft  cataracts  sometimes  take  to  disappear  by  solution  in  the  aque- 
ous humour,  added  to  the  fact  that  not  only  is  the  patient  apt  to 
grow  anxious  and  to  lose  his  health,  but  the  eye  to  become  affected 
with  chronic  irritability  and  inflammation,  under  this  prolonged 
mode  of  cure.  Mr.  Gibson  first  of  all  freely  ruptured  the  anterior 
hemisphere  of  the  capsule  with  the  needle,  and  after  two  or  three 
weeks,  proceeded  to  extract  the  pulpy  lens.  For  this  purpose  he 
punctured  the  cornea  near  its  temporal  edge  with  a  broad  extrac- 
tion-knife, and  if  he  had  any  doubt  of  the  capsule  having  been 
freely  lacerated  in  the  former  operation,  he  directed  the  point  of 
the  knife  obliquely  through  the  pupil,  so  as  to  make  a  more  free 
division  of  the  capsule.  On  withdrawing  the  knife,  part  of  the 
aqueous  humour,  and  some  portion  of  the  cataract  were  evacuated. 
The  curette  was  next  introduced  through  the  incision,  and  towards 
the  pupil  ;  and  by  that  instrument  the  whole  of  the  cataract  was 
commonly  removed  by  degrees,  and  the  pupil  rendered  perfectly 
clear.  Its  removal  was  generally  much  facilitated  by  gentle  pres- 
sure towards  the  vitreous  humour,  with  the  convex  surface  of  the 
curette,  whilst  the  point  was  inserted  through  the  pupil. 

Mr.  Gibson  observes  that  it  occasionally  happens  that  upon  in- 
troducing the  curette,  a  considerable  part  of  the  cataract  appears 
too  solid  for  removal,  and  only  a  small  portion  escapes  in  a  pulpy 
state.  The  nucleus  of  the  lens  is  sometimes  much  more  soHd  than 
the  rest,  and  will  not  be  easily  extracted  in  this  way ;  yet,  much 
oftener  the  difficulty  arises  wholly  from  the  smallness  of  the  aper- 
ture in  the  capsule,  so  that  it  allows  only  an  inconsiderable  part  of 


526 

the  cataract  to  pass  out  at  a  time,  the  capsule  having  perhaps  been 
tougher  than  usual,  and  not  easily  lacerated  in  the  preparatory 
operation  with  the  needle.  In  such  a  case,  the  opening  into  the 
capsule  may  be  extended  either  by  means  of  the  curette,  or  by  the 
small  hook  commonly  used  for  lacerating  the  capsule  ;  or  if  this 
membrane  appears  uncommonly  firm,  it  may  be  divided  with  the 
iris-scissors. 

Mr.  Gibson  concludes  that  by  this  operation  the  repeated  use  of 
the  needle  may  be  safely  superseded,  and  with  less  risk  of  inflam- 
mation or  injury  to  the  eye.  He  adds,  that  in  many  instances,  no 
traces  of  inflammation,  or  of  any  operation,  could  be  seen  on  the 
eye  the  next  day ;  nor  had  the  iris  ever  been  injured,  or  even  ir- 
ritated in  the  slightest  degree,  by  the  use  of  the  curette.* 

This  method  of  removing  soft  cataract  has  been  adopted  by 
Mr.  Travers,  with  the  difference,  that  instead  of  opening  the  cap- 
sule with  the  needle  passed  through  the  sclerotica,  and  then  wait- 
ing for  two  or  three  w^eeks,  he  begins  his  operation,  having  pre- 
viously dilated  the  pupil,  by  a  quarter-section  of  the  cornea,  dipping 
the  point  of  the  knife  into  the  pupil,  and  freely  lacerating  the 
capsule.  The  fluid  cataract,  he  states,  is  instantly  evacuated  with 
the  aqueous  humour  ;  the  flocculent  cataract  frequently  passes  out 
entire,  taking  an  oblong  shape  ;  and  the  caseous  cataract  piece- 
meal, through  the  hollow  of  the  scoop,  on  gently  depressing  the 
margin  of  the  pupil.t 

3.  Mr.  Travers,^  Sir  William  Adams,?  and  others,  have  w^ith 
more  or  less  success  had  recourse  also  to  the  extraction  of  firm 
cataracts  through  a  small  section  of  the  cornea. 

The  pupil  being  previously  dilated  by  belladonna,  the  steps  of 
the  operation  are,  to  slit  open  the  capsule  with  a  small  bent  needle, 
introduced  through  the  sclerotica ;  tilt  the  lens  forward  through 
the  pupil ;  keep  it  fixed  by  means  of  the  needle,  which  may  now 
be  committed  to  the  charge  of  the  assistant ;  open  the  circum- 
ference of  the  cornea  to  about  one-third  of  its  extent;  withdraw 
the  needle ;  introduce  a  hook,  lay  hold  of  the  lens,  and  extract  it. 

The  opening  in  the  capsule  will  require  to  extend  to  its  whole 
diameter,  else  the  dislocation  of  the  lens  will  not  be  easily  accom- 
plished. The  dislocation  is  usually  effected  by  pressing  with  the 
needle  near  the  lower  or  upper  edge  of  the  lens,  so  that  the  opposite 
edge  from  that  which  is  pressed  upon  is  tilted  forwards  through 
the  pupil ;  and  it  matters  little  whether,  in  doing  so,  the  lens  re- 
volves, so  that  its  posterior  surface  comes  to  be  applied  against  the 
cornea,  or  not.  If  the  operator  is  satisfied  that  the  capsule  is  suf- 
ficiently opened,  and  yet  fails  in  bringing  the  lens  forwards  by 

*  Practical  Observations  on  the  Formation  of  an  artificial  Pupil ;  to  which  are  an- 
nexed, Remarks  on  the  Extraction  of  Soft  Cataracts,  &c.  p.  103.     London,  1811. 

t  Further  Observations  on  the  Cataract;  in  the  Medico-Chirurgical  Transactions, 
vol.  V.  p.  406.     London,  1814.  t  Ibid. 

§  Practical  Inquiry  into  the  Causes  of  the  Frequent  Failure  of  the  Operations  of 
Depression  and  Extraction,  pp.  138  and  283.     London,  1817. 


527 

pressing  back  one  or  other  of  its  edges,  he  may  withdraw  the 
needle  from  the  posterior  chamber  by  carrying  it  under,  and  hence 
behind  the  lens,  which  he  must  then  attempt  to  push  forwards 
through  the  pupil.  Keeping  the  needle  in  contact  with  the  lens 
till  the  section  is  finished,  or  even  retaining  it  in  the  eye  till  the 
cataract  is  extracted,  is  of  great  use,  as  it  secures  us  against  the 
lens  falhng  back  into  its  former  situation.  The  incision  of  the 
cornea  is  to  be  executed  exactly  in  the  same  manner  as  the  semi- 
circular incision,  only  that  it  is  less  in  size.  The  hook  is  to  be 
introduced,  flat,  between  the  lens  and  the  iris,  as  far  as  the  centre 
of  the  pupil ;  the  curved  point  of  the  instrument  is  then  to  be  turned 
forwards,  and  the  cataract  laid  hold  of.  The  extraction  is  accom- 
plished without  any  pressure  on  the  eye,  which  constitutes  the 
great  recommendation  of  this  mode  of  operating,  in  cases  where 
we  have  reason  to  suspect  that  the  hyaloid  membrane  is  unsound. 

III.  Extraction  through  the  Sclerotica. 

Mr.  B.  Bell  appears  to  have  been  the  first*  to  suggest  this  mode 
of  operating,  as  one  which  was  not  only  practicable,  but  in  which 
the  cornea  and  iris  would  be  exempt  from  all  direct  injury.  His 
experiments  on  the  lower  animals  led  him  to  believe,  that  the  in- 
flammation induced  by  an  incision  through  the  sclerotica  was  not 
more  considerable,  nor  the  cure  in  any  respect  more  difficult,  than 
when  extraction  was  performed  in  the  usual  manner.  He  recom- 
mended the  opening  to  be  made  in  the  upper  part  of  the  %ye,  the 
knife  being  entered  about  the  tenth  of  an  inch  behind  the  cornea, 
the  incision  to  be  of  sufficient  size  for  allowing  the  cataract  to  pass, 
and  a  sharp  curved  probe  to  be  introduced,  the  point  of  which  to 
penetrate  the  lens,  whicli  might  by  this  means  be  removed  without 
any  pressure  upon  the  eyeball.t 

For  extraction  through  the  sclerotica,  Sir  James  Earle  invented 
an  instrument,  consisting  of  a  small  lancet,  moving  backwards  and 
forwards  between  the  blades  of  a  pair  of  forceps.  This  instrument 
being  introduced  through  the  sclerotica  and  choroid,  the  lancet  is 
withdrawn  by  means  of  a  spring  contained  within  the  handle, 
while  the  forceps  is  left  behind.  The  blades  are  then  opened,  and 
the  cataract  seized  and  brought  away.  Sir  James  entered  the  in- 
strument just  behind  the  iris.  In  the  first  three  operations  which 
he  has  related,  he  introduced  it  in  such  a  manner  that  the  incision 
ran  parallel  to  the  edge  of  the  cornea,  and  of  course  divided  a  con- 
siderable number  of  the  choroidal  vessels ;  but  in  his  fourth  opera- 
tion he  appears  to  have  introduced  the  instrument  in  such  a  man- 
ner, that  the  incision  would  form  a  line  perpendicular  to  the  edge 

*  Dr.  Lobenstien-Lobel  has  conjectured  that  extraction  through  the  sclerotica  was 
the  method  adopted  by  Kerkringius,  Burrhus,  Ta3dor,  and  Woolhouse,  when  they 
boasted  of  having  restored  a  ycung  and  acute  vision  to  aged  people,  by  removing  the 
corrupted  and  turbid  humours  of  the  eye,  and  replacing  new  ones  in  their  stead  ;  but 
this  is  very  unlikely. 

t  System  of  Surgery,  Vol.  iv.  p.  246.    Edinburgh,  1796. 


528 

of  the  cornea,  or,  in  other  words,  run  parallel  to  the  course  of  the 
choroidal  arteries.  Having  retracted  the  lancet,  he  then  turned  the 
forceps  round,  so  that  they  might  embrace  the  cataract ;  a  mode 
of  procedure  by  which  he  thinks  a  discharge  of  vitreous  humour 
less  likely  to  occur.  He  states,  also,  that  the  wound  which  is  made 
perpendicularly  to  the  edge  of  the  cornea  heals  with  the  same  fa- 
cility as  the  other.* 

The  following  are  some  of  the  advantages,  mentioned  by  Sir 
James,  as  possessed  by  extraction  through  the  sclerotica.  The 
wound  need  not  exceed  a  fourth  of  the  size  of  the  incision  required 
in  the  ordinary  operation  of  extraction  through  the  cornea  ;  in 
the  passage  of  the  forceps  through  the  vitreous  humour  and  in  the 
use  of  them  afterwards,  not  nearly  so  much  derangement  of  the 
interior  of  the  eye  is  produced  as  attended  the  employment  of  the 
needle  in  the  old  operation  of  couching  ;  the  part  through  which 
the  incision  is  made  is  immovable,  consequeutly  the  edges  of  it 
must  remain  in  contact,  and  heal  with  comparative  facility.t 

A  remarkable  case  of  wound  of  the  eye,  attended  with  evacua- 
tion of  the  lens,  had  led  Dr.  Lobenstein-Lobel  to  form  a  favoura- 
ble opinion  of  extraction  through  the  sclerotica,!  but  he  does  not 
appear  to  have  ever  put  this  operation  in  practice. 

I  lately  extracted  a  crystalline  lens  from  under  the  conjunctiva ; 
it  having  been  propelled,  by  a  smart  blow  on  the  eye,  through  a 
laceration  of  the  choroid  and  sclerotica.  The  opening  through 
these  tunics  was  already  healed,  the  pupil  clear,  and  the  retina 
perfectly  sensible.  Such  facts  as  this  would  lead  us  to  pause  be- 
fore rejecting,  so  absolutely  as  some  have  done,  the  operation  of 
extraction  through  the  sclerotica. 

I  cannot  pretend  to  speak  with  much  precision  of  an  operation 
which  I  have  nev^er  attempted  on  the  human  eye.  I  should  con- 
sider it  proper,  however,  to  divide  the  capsule  with  the  needle  be- 
fore opening  the  sclerotica  and  choroid  with  the  knife ;  to  select 
the  upper  part  of  the  eyeball  for  the  incision  ;  to  make  it  perpen- 
dicular, not  parallel,  to  the  edge  of  the  cornea  ;  and  to  extract  the 
lens  with  a  hook.  Of  course,  pressure  on  the  eyeball  is  in  this 
operation  altogether  out  of  the  question. 


SECTION  XI. DIVISION. 

I.  Division  through  the  Sclerotica.X 
Ever  since  the  days  of  Celsus,§  division  of  the  cataract  with  the 

*  From  some  experiments  which  I  have  made  on  the  lower  animals,  1  am  convinced 
that  an  incision  through  the  sclerotica  perpendicular  to  the  edge  of  the  cornea  gapes 
less,  and  therefore  heal  sooner  than  one  parallel  to  the  edge  of  the  cornea. 

t  Account  of  a  New  Mode  of  Operation  for  the  Removal  of  Cataract.  London, 
1801. 

X  Edinburgh  Medical  and  Surgical  Journal.     Vol.  xiii.  p.  56.     Edin.  1817. 

§   Die  Pott'  sche  Operationsmethode  of  the  Germans. 

II  Si  subinde  redit,  eadem  acu  magis  concidenda,  et  in  plures  partes  dissipanda  est. 
Celsus  de  Re  Medica,  Lib.  vii.  Pars  ii.  Cap.  i.  Sect  ii. 


529 

couching  needle  has  been  regarded  as  a  proper  supplementary  step 
to  displacement,  when  this  could  not  be  perfectly  performed.  Bar- 
bette, Read,  and  Maitre-jan,  all  availed  themselves  of  their  know- 
ledge of  the  fact,  that  a  cataract  which  had  been  merely  cut  up 
and  left  in  its  ordinary  situation,  would  after  a  certain  length  of 
time  entirely  disappear.  Barbette  states,  that  in  such  circumstan- 
ces, vision  would  be  restored  after  seven  or  eight  weeks ;  *  Read 
employs  the  words  consumed  and  dispersed^  to  express  the  dis- 
appearance of  the  pieces  of  the  divided  cataract ;  t  Maitre-jan  ob- 
serves that  this  disappearance,  which  he  styles  a  precipitation^ 
takes  place  as  well  in  the  anterior  as  in  the  posterior  chamber,  and 
notices  its  connexion  with  a  laceration  of  the  capsule.t  Pott  ap- 
pears to  have  been  the  first,  not  merely  to  make  use  of  the  term 
which  we  now  employ,  namely,  dissolution,  but  to  adopt  a  lacera- 
tion of  the  capsule  as  a  distinct  mode  of  operating,  independent  of 
depression.  § 

It  is  evident,  that  in  this  mode  of  operating,  the  object  is  not  im- 
mediately to  remove  the  cataract,  but  merely  to  expose  it  to  a  nat- 
ural means  of  cure,  namely,  the  solvent  action  of  the  aqueous  hu- 
mour. This  may  be  done  in  two  ways ;  viz.  first,  by  destroying 
the  front  of  the  capsule,  so  that  the  aqueous  humour  gains  admit- 
tance to  the  lens  ;  and,  secondly,  by  dividing  the  lens  into  frag- 
ments, and  pushing  these  into  the  aqueous  humour.  Both  of  these 
objects  may  be  attempted  at  one  operation  ;  but  it  is  better  to  ope- 
rate twice  than  to  do  too  much  at  once,  and  to  confine  ourselves  in 
the  first  operation  to  the  division  of  the  capsule  only.  The  caution. 
deUvered  by  Mr,  Hey  is  peculiarly  applicable  to  the  operation  of 
division.  "  One  principal  thing,"  says  he,  "  to  be  kept  in  view  by 
the  operator,  is  to  do  no  harm.  If  he  secures  this,  he  will  almost 
certainly  do  some  good,  and  often  much  more  good  than  he  ex- 
pects."|| 

Division  through  the  sclerotica  naturally  divides  itself  into  four 
periods.  In  the  first,  the  needle  is  introduced  through  the  tunics, 
and  into  the  vitreous  humour  ;  in  the  second,  the  instrument  en- 
ters the  posteiior  chamber  ;  in  the  third,  the  anterior  hemisphere 
of  the  capsule  is  divided  ;  in  the  fourth,  the  lens  is  cut  into  frag- 
ments, and  these  are  pushed  into  the  anterior  chamber. 

*  Etiamsi  sufficienter  depressa  haud  erit  cataracta,  visum  tamen  saspe  post  septima- 
nas  septem  vel  octo  rediisse,  in  variis  observavi,  modo  in  partes  varias  divisa  fuerit. 
Pauli  Barbette,  Opera  Chirurgico-Anatomica,  p.  66.  Lugd.  Batav.  1672. 

t  Short  but  Exact  Account  of  all  the  Diseases  incident  to  the  Eyes.     London,  1706. 

t  Traite  des  Maladies  de  I'CEil,  p.  186.    Troyes,  1711. 

§  I  have  sometimes,  when  I  have  found  the  cataract  to  be  of  the  mixed  kind,  not 
attempted  depression  :  but  have  contented  myself  with  a  free  laceration  of  the  capsula  ; 
and  having  turned  the  needle  round  and  round  between  my  finger  and  thumb,  within 
the  body  of  the  crystalline,  have  left  all  the  parts  in  their  natural  situation  :  in  which 
cases  I  have  hardly  ever  known  them  fail  of  dissolving  so  entirely  as  not  to  leave  the 
smallest  vestige  of  a  cataract.  Chirurgical  Works,  vol.  iii.  p.  156.  London,  1808. 
Mr.  Pott  first  published  his  remarks  on  the  Cataract  in  1775. 

II  Practical  Observations  in  Surgery,  p.  72.     London,  1803. 

67 


530 

The  pupil  is  to  be  dilated,  in  the  manner  mentioned  at  page 
502. 

Whether  a  straight  or  bent  needle  is  chosen,  the  neck  of  the  in- 
strument must  be  round,  its  edges  perfectly  sharp,  and  its  size  rath- 
er under  than  above  the  measurements  stated  at  page  503. 

The  first  and  second  jieriods  of  the  operation  are  exactly 
the  same  with  those  of  depression  and  reclination,  as  already  de- 
scriljed. 

3o?.  Period.  The  needle  having  reached  the  centre  of  the  pos- 
terior chamber,  the  operator  turns  its  cutting  edge  towards  the 
capsule,  and  proceeds  by  numerous  gentle  touches  of  the  instru- 
ment, to  cut  up  that  membrane  into  shreds,  to  an  extent  rather  ex- 
ceeding than  falling  wi'.hin  the  natural  size  of  the  pupil.  The  ob- 
ject is  entirely  to  annihilate  this  central  portion  of  the  capsule,  and 
thus  allow  the  aqueous  humour  free  access  to  the  lens.  Merely  to 
pierce  the  capsule,  slit  it  up,  or  tear  it  from  the  front  of  the  lens, 
would,  in  all  probability,  not  answer  the  purpose,  because  the  por- 
tions of  the  capsule  thus  treated  would  speedily  reunite,  and  the 
absorption  of  the  lens  be  interrupted.  Neither  is  it  desirable  to  open 
the  capsule  in  the  whole  of  its  diameter,  because  this  would  most 
likely  be  followed  by  dislocation  of  the  lens,  which  would  conse- 
quently press  against  the  iris,  or  pass  entire  through  the  pupil  into 
the  anterior  chamber. 

If  the  lens  be  fluid,  it  will  escape  into  the  aqueous  humour  and 
render  it  turbid,  as  soon  as  the  capsule  is  opened  ;  and  if  soft  and 
friable,  portions  of  it,  towards  the  end  of  this  period  of  the  operation, 
will  generally  be  observed  to  break  off,  and  float  forwards  through 
the  pupil. 

If  this  be  the  first  operation  which  the  cataract  has  undergone, 
the  needle  should  be  withdrawn  as  soon  as  the  division  of  the  cap- 
sule is  completed. 

A:th  Period.  It  sometimes  happens  that  the  division  of  the  cap- 
sule, in  the  manner  and  to  the  extent  above  stated,  is  sufficient^ 
without  any  further  operation,  to  procure  the  absorption  of  the  lens, 
and  the  restoration  of  vision.  Much  oftener  the  operation  of  di- 
vision requires  to  be  repeated  after  the  interval  of  two  or  three 
months  ;  and  at  the  second  operation,  particular  attention  requires 
to  be  paid  to  the  breaking  up  of  the  lens  and  dispersion  of  its  frag- 
ments. 

The  needle  being  introduced  as  before,  the  operator  begins  the 
division  exactly  as  he  began  the  former  operation,  lest  the  shreds  of 
the  capsule  may  in  the  interval  have  more  or  less  completely 
coalesced,  and  therefore  require  to  be  separated  and  broken  down. 
Having  assured  himself  of  the  existence  of  a  sufficient  central 
aperture  in  the  capsule,  the  operator  next  proceeds  by  gentle  move- 
ments of  the  needle  from  side  to  side,  to  break  the  lens  in  pieces, 
and  pushes  these  from  time  to  time,  as  he  proceeds,  through  the 
pupil,  into  the  anterior  chamber.     In  dividing  the  lens,  it  is  some- 


531 

times  necessary  to  move  the  edge  of  the  needle  backwards,  or 
towards  the  vitreous  humour ;  but  this  direction  ought  rather  to  be 
avoided,  in  order  that  the  posterior  capsule  may,  if  possible,  remain 
entire,  for  if  it  be  much  injured,  it  is  apt  to  become  opaque,  an  oc- 
currenee  rendering  necessary  new  operations,  which  endanger  the 
organization  of  the  vitreous  humour. 

It  is  by  no  means  essential,  even  for  speedy  solution,  that  the 
pieces  of  the  divided  lens  be  brought  into  the  anterior  chamber. 
Some  have  been  led  to  think  that  solution  is  accomplished  fully  as 
quickly  when  the  lens,  stript  of  its  capsule,  is  left  in  its  natural  sit- 
uation. No  doubt,  the  greater  quantity  of  the  menstruum  by 
which  the  solution  is  to  be  effected,  lies  in  the  anterior  chamber  5 
but,  on  the  other  hand,  it  is  probable  that  this  menstruum  is  se- 
creted chiefly  (if  not  entirely)  in  the  posterior  chamber,*  and  it  is 
possible  that  it  may  possess  more  of  the  solvent  power  when  just 
flowing  from  the  capillaries  which  secrete  it,  than  after  it  has 
passed  forward  through  the  pupil,  and  is  about  to  be  absorbed. 
Others  have  been  of  opinion,  that  the  removal  of  the  opaque  lens, 
after  the  capsule  is  opened  up  with  the  needle,  is  to  be  attributed 
perhaps  as  much  to  the  action  of  the  absoibents  of  the  lens  itself, 
stimulated  by  the  presence  of  the  aqueous  humour,  as  to  the  opera- 
tion of  this  fluid  in  the  way  of  menstruum.t 

The  facility  with  which  tLe  fragments  of  the  divided  lens  are 
scattered  by  the  needle,  does  not  depend  so  much  on  its  consistence, 
as  on  the  degree  of  coagulation  w^hich  it  has  undergone.  In  pa- 
tients about  the  age  of  25.  we  not  unfrequentiy  find  the  lens  so  soft 
that  the  needle  passes  easily  through  it  in  every  direction,  but  at 
the  same  time  so  glutinous  and  tenacious,  that  the  fragments  can 
be  separated  with  diinculty ;  whereas  in  patients  of  35,  the  lens  is 
generally  more  friable,  and  breaks  easily  under  the  needle  into 
scales  and  flocculi.  By  exposure,  however,  to  ti;e  aqueous  humour 
for  a  few  weeks,  the  glutinous  lens  becomes  more  completely  coagu- 
lated, and  then  its  fragments  prove  less  adherent.  Even  the  hard 
lens  of  an  old  person,  if  exposed  for  some  time  to  the  influence  of 
the  aqueous  humour,  occasionally  becomes  brittle,  so  that  at  a 
second  operation  with  the  needle,  (the  first  operation  having  been 
devoted  to  the  destroying  of  the  anterior  capsule,)  we  find  the  lens 
to  scatter  into  fragments.  This  is  an  occurrence,  however,  too 
rare,  to  vindicate  us  in  adopting  division  as  a  general  mode  of  ope- 
rating on  the  hard  cataract  of  old  persons. 

What  length  of  time  is  generally  required  for  the  cure  of  cataract 
by  absorption  ?  To  this  I  am  inclined  to  answer,  that  we  have  no 
evidence  to  prove  that  the  capsule  is  ever  absorbed,  whether  it  be 
in  the  transparent  or  in  the  opaque  state ;  and  that  as  for  the  lens, 
the  rapidity  with  which  it  is  dissolved,  depends  partly  on  its  con- 
sistence, and  partly  on  the  completeness  with  which  it  is  exposed 

*  See  p.  423.     t  De  la  Garde's  Treatise  on  Cataract,  p.  51.    London,  1821. 


532 

to  the  aqueous  humour.  If  in  a  person  below  35  years  of  age,  the 
central  portion  of  the  anterior  capsule  be  thoroughly  destroyed  with 
the  needle,  and  if  no  inflammation  follows  the  operation,  the  lens 
may  be  completely  dissolved  and  absorbed  in  six  weeks.  Of  course, 
the  fluid  lens  of  the  child  will  be  absorbed  in  a  few  days,  while  the 
hard  lens  of  55  or  60  may  remain  almost  unchanged  for  several 
months.  We  constantly  observe  that  solution  and  absorption  go 
on  much  more  rapidly  when  the  eye  is  free  from  inflamniation  or 
irritation.  Indeed  during  an  attack  of  pain,  with  redness  and 
epiphora,  solution  and  absorption  seem  to  cease,  but  are  renewed 
whenever  the  irritation  subsides,  or  the  inflammation  is  overcome. 
We  explain  this,  partly  by  the  well  known  fact  that  over-distension 
of  the  blood-vessels  is  always  found  to  be  inconsistent  with  a  free 
action  of  the  absorbents,  and  partly  by  this,  that  even  although 
there  may  be  no  evident  effusion  of  lymph  behind  the  pupil,  there 
is  always  a  tendency  in  internal  ophthalmia  to  such  an  effusion, 
and,  of  course,  a  tendency  to  close  up  and  repair  the  injured  cap- 
sule, an  effort  of  nature,  which  however  admirable  its  design,  we 
must  in  this  instance  endeavour  to  counteract,  by  as  complete  a 
division  of  the  capsule,  in  the  first  instance,  as  is  possible,  and, 
secondly,  by  a  strict  antiphlogistic  after-treatment. 

The  opinion  above  stated,  that  the  capsule,  so  far  as  we  know, 
is  insoluble,  is,  I  am  aware,  in  contradiction  to  what  has  usually 
been  maintained  upon  this  point.  The  capsule  in  the  transparent 
state  we  never  see  ;  its  shreds  are  invisible  from  the  very  circum- 
stance of  their  transparency.  This  membrane  too  is  highly  elastic, 
and  upon  being  divided,  rolls  itself  up  like  a  bit  of  goldbeater's  leaf. 
But  if  inflammation  occurs,  the  capsule  becomes  opaque,  and,  un- 
less the  inflammation  is  speedily  subdued,  will  continue  perma- 
nently so.  The  opaque  shreds  in  the  inflamed  state  tend  also  to 
reunite,  and  thus  give  rise  to  a  secondary  capsular  cataract.  Sub- 
due the  inflammation  by  blood-letting,  mercury,  and  other  appro- 
priate remedies,  and  the  opacity  of  the  capsule  subsides  or  entirely 
disappears.  Neglect  it,  and  not  merely  does  the  opacity  become 
permanent,  but  however  much  the  capsule  may  afterwards  be  di- 
vided, its  shreds  never  disappear,  except  by  displacement.  They 
may  be  pushed  aside,  a  central  aperture  cleared,  and  vision  re- 
stored ;  but  portions  of  opaque  capsule  will  be  visible  for  life  behind 
the  edge  of  the  pupil,  brought  under  the  influence  of  belladonna, 
and  the  minute  shreds  which  fell  down  into  the  anterior  chamber, 
will  lie  there  without  undergoing  the  slightest  change.  It  is  proba- 
ble, that  the  return  of  transparency,  after  inflammation  of  the  cap- 
sule is  overcome,  has  given  rise  to  the  erroneous  opinion  that  this 
membrane  is  susceptible  of  solution  in  the  aqueous  humour. 

Modifications  of  division  through  the  sclerotica,  according 
to  varieties  of  cataract.  1.  When  the  lens  is  fluid,  it  will  of 
course  flow  through  the  wound  of  the  capsule  into  the  aqueous 
hiimour.     This  renders  it  difficult  to  execute  the  division  of  the 


533 

capsule  with  precision.  It  is  desirable,  however,  that  the  centre 
of  it  should  be  freely  lacerated.  The  turbid  aqueous  humour  is 
generally  absorbed  in  a  few  days.  In  some  rare  cases,  the  effusion 
of  the  opaque  lens  excites  considerable  inflammation. 

2.  The  appearances  of  the  opacity,  added  to  the  age  of  the  pa- 
tient, should  in  genei'al  be  sufficiently  indicative  of  hard  cataract ; 
and  in  cases  of  this  sort,  division  ought  never  to  be  tried.  Should 
the  operator,  however,  have  deceived  himself,  and  supposed  the 
lens  to  be  soft  when  by  touching  it  with  the  needle  he  discovers  it 
to  be  hard,  the  best  plan  which  he  can  follow  is  to  bring  the  lens 
through  the  pupil,  open  one-third  of  the  circumference  of  the  cornea, 
and  extract. 

3.  When  the  edge  of  the  pupil  is  adherent  to  the  capsule,  which 
in  this  case  is  always  more  or  less  opaque,  we  may  endeavor  with 
the  point  or  edge  of  the  needle  cautiously  to  separate  the  points  of 
adhesion,  particularl)'^  if  they  are  but  few  in  number,  and  having 
effected  this,  proceed  to  the  division  of  the  capsule  in  the  usual 
way.  If  the  adhesion  comprehends  the  whole  edge  of  the  pupil, 
separation  is  scarcely  to  be  accomplished  ;  but  if  the  pupil  is  of  a 
medium  size,  it  is  not  necessary  for  the  restoration  of  sight  that 
the  iris  should  be  freed  from  its  attachment  to  the  capsule.  Enough 
of  the  capsule  can  in  this  case  be  divided  to  admit  the  aqueous 
humour  freely  to  the  lens,  and  we  probably  run  less  risk  of  renewed 
iritis  when  we  confine  ourselves  to  the  clearing  away  of  the  centre 
of  the  capsule  than  were  we  to  attempt  the  separation  of  the  mor- 
bid adhesions  of  the  iris. 

After-treatment.  Except  in  continued  dilatation  of  the  pupil, 
this  does  not  differ  from  the  treatment  already  recommended  as 
advisable  after  the  operations  of  displacement.  If  the  pupil  is  kept 
under  the  influence  of  belladonna,  the  fragments  of  the  divided 
lens  are  in  a  great  measure  prevented  from  irritating  the  iris,  and 
thus  iritis  is  waided  off.  It  is  pioper,  therefore,  to  smear  the  eye- 
brow and  eyelids  with  the  extract  of  belladonna  every  evening, 
till  the  cure  is  completed.  Should  this  mode  of  application  appear 
to  fail  in  producing  the  desired  effect,  a  httle  of  an  aqueous  solu- 
tion of  the  extract,  made  lukewarm,  may  be  dropped  into  the  inner 
corner  of  the  eye,  the  patient  opening  the  eye  and  allowing  the 
solution  to  spread  over  the  conjunctiva.  The  solution  ought  to  be 
filtered  immediately  before  using  it. 

Accidents  duri?ig  and  after  division  through  the  sclerotica. 
Many  of  these  are  exactly  similar  to  those  which  are  apt  to  attend 
the  operations  of  displacement,  and  need  not  again  be  particularly 
insisted  on. 

1.  The  needle,  instead  of  entering  the  posterior  chamber,  some- 
times slips  between  the  lens  and  the  capsule.  As  it  is  impossible 
with  the  needle,  in  this  situation,  to  divide  the  capsule  in  a  proper 
manner,  the  operator  ought  to  withdraw  the  instrument  a  certain 
way,  and  then  repeat  the  second  period  of  the  operation,  taking 
care  to  bring  the  point  of  the  needle  in  front  of  the  capsule. 


534 

2.  Should  it  happen,  in  consequence  of  an  improper  use  of  the 
needle,  that  the  lens  bursts  from  the  capsule,  and  passes  through 
the  pupil  into  the  anterior  chamber,  the  cornea  should  immediately 
be  opened  in  the  manner  described  at  page  526,  and  the  lens  ex- 
tracted 

3.  If  the  hyaloid  membrane  is  in  a  dissolved  state,  the  lens  and 
capsule,  hitherto  kept  in  their  place  by  the  adhesion  of  the  circura- 
fereuce  of  the  capsule  to  the  ciliary  processes,  are  apt,  on  being 
touched  with  the  needle,  suddenly  to  sink  to  the  bottom  of  the 
vitreous  humour.  In  this  case,  the  cataract  ought  immediately  to 
be  laid  hold  of  with  the  needle,  brought  up  into  its  former  place, 
pushed  through  the  pupil,  and  extracted  through  a  small  section  of 
the  cornea. 

4.  A  certain  degree  of  inflammation  may  always  be  expected  to 
follow  division  through  the  sclerotica ;  reparative  inflammation  of 
the  capsule,  spreading  in  some  degree  to  the  iris,  and  if  not  timely 
checked,  producing  opacity  of  the  capsular  shreds,  closing  up  the 
central  aperture  which  has  been  formed  by  the  operation,  interrupt- 
ing in  various  ways  the  process  of  dissolution  of  the  lens,  and  per- 
haps going  the  length  of  coarctation  of  the  pupil  and  adhesion  of 
the  iris.  Belladonna,  blood-letdng,  and  calomel  with  opium,  are 
the  means  to  be  employed  to  avert  these  dangers. 

5.  Has  the  process  of  solution  and  absorption  of  the  lens  no  ex- 
hausting effects  upon  the  internal  parts  of  the  eye  ?  Are  these 
parts  left  as  sound,  after  this  process  has  been  accomplished,  as 
after  extraction,  in  neither  case  inflammation  having  occurred? 
To  these  questions,  I  must  answer,  that  after  the  process  of  solu- 
tion and  absorption  is  completed,  we  frecjuently  observe  undeniable 
signs  of  the  internal  textures  of  the  eye  having  suffered,  not  from 
inflammation  apparently,  nor  from  irritation,  but  rather  from  exhaus- 
tion. The  iris,  particularly,  becomus  paler  and  more  flaccid  than 
natural,  the  pupil  smaller,  and  its  motions  less  vivid  ;  while,  in 
some  cases,  the  wasting  of  the  eye  extends  more  deeply,  the 
vitreous  humour  shrinks,  and  the  retina  becomes  more  or  less  in- 
sensible. 

II.  Division  through  the  Cornea* 
It  has  been  conjectured  that  this  is  a  very  ancient  method  of 
curing  cataract.  Galen  mentions  that  there  was  a  tradition,  that 
for  the  operation  for  the  cure  of  cataract  man  was  indebted  to  what 
was  observed  to  happen  to  the  goat,'  v^^hich  after  pricking  his  eye 
against  a  sharp  reed,  retained  the  power  of  sight ;  t  whence  it  has 
been  thought  that  the  first  operation  practised  for  the  cure  of  cata- 
ract may  have  been  a  division  or  punctuation  of  the  lens  through 
the  cornea. 

*  Keratonyxis  of  the  Germans  ;  from  xsgstf,  comu,  whence  cornea,  and  yuTrai,  to 
puncture. 

T  T/v*  Si  ix.  Tri^iTTTaia-ias;  ^u.ti  Trmivona-QsLi.  ai;  to  tt^fictKevrejv  tovc  vTromyv/mvcvc  at  tou 
TrtgnrtTw  ttiya.,  «t/j  Trigi^Qj^uva.  ttnQKi^iv,  o'^uj-^oivw  ifA7rttyit<ni;  m  tov  6ipdcO./A0V.  Txhuvou 
BtvAyuy))  n  la.T^o(.     Librorum  Pars  IV.  p.  371.     BasilesB,  1538. 


535 

Albucasis  tells  us  that  he  had  been  informed  there  were  some 
who  pumped  out  the  cataract  through  a  hollow  needle.*  Now,  in 
cases  of  fluid  cataract,  there  is  no  doubt  that  the  gutta  opaca,  in 
which  the  Arabians  believed  cataract  to  consist,  might  be  discharged 
through  a  tube  introduced  (I  presume)  through  the  cornea ;  but 
even  when  the  cataract  was  not  fluid,  and  when  only  the  aqueous 
humour  was  discharged,  even  a  very  slight  wound  through  the 
anterior  hemisphere  of  the  capsule  with  the  end  of  the  tube,  would 
frequently  be  sufficient  to  produce  a  cure,  by  the  admission  of  the 
aqueous  humour.  We  shaii  presently  see  that  the  operation  pro- 
posed by  Conradi  amounted  to  little  more  than  such  a  perforation 
of  the  capsule. 

There  is  an  insulated  case  recorded  by  Mayerne,  in  which  a 
female  oculist  appears  to  have  cured  a  case  of  cataract  in  a  young 
person,  by  the  introduction  of  a  needle  through  the  cornea.t  This 
case  is  generally  considered  as  the  earliest  example  of  an  attempt 
to  procure  the  solution  of  the  lens  by  puncturing  the  capsule  through 
the  cornea.  It  is,  however,  not  very  evident  what  was  the  inten- 
tion of  the  operator,  and,  except  from  the  circumstance  of  its  being 
placed  in  a  chapter  De  Suffusione^  we  should  not  have  known 
that  it  was  a  case  of  cataract  at  all. 

Gleize  deserves  to  be  mentioned  in  a  history  of  the  operation  of 
division  through  the  cornea,  although  his  claims  have  been  strangely 
exaggerated.  It  happened  that  a  patient  on  whom  he  was  about 
to  perform  the  operation  of  extraction,  made  an  involuntary  motion 
with  her  head,  just  as  the  knife  had  penetrated  the  cornea,  so  that 
the  knife  shpped  out  from  the  pimctured  incision,  and  was  fol- 
lowed by  the  aqueous  humour.  Instead  of  enlarging  the  incision 
with  the  scissors,  it  occurred  to  the  operator,  that  he  might  depress 
the  cataract  through  the  wound  of  the  cornea,  which  he  accordingly 
did.  He  says  nothing  about  dividing  the  cataract,  or  exposing  it 
to  solution  in  the  aqueous  humour.t    His  successful  depression  in 

*  Et  jam  quidem  pervenit  ad  nos  de  quodam  ex  illis  qui  sunt  de  Alayrach,  quia 
[qui]  dixit  quod  factum  fuit  in  Alayrach  magdaham  perforatum  quo  sugit  aqua  [aquam.] 
Verum  ego  non  vidi  aliquem  in  terra  nostra  qui  fecerit  illud,  neque  legi  illud  in  aliquo 
ex  libris  antiquorum  et  est  possibile  ut  sit  illud  novum,  et  istae  sunt  formse  specierum 
magdaham.  [Here  Albucasis  gives  three  figures.]  li'iant  formae  prsedictae  ex  sere, 
et  sint  extremitates  earum  subtiles,  sit  triangulata  extremitas  acuta.  Methodus  Me- 
dendi,  autore  Albucase,  p.  68.  Basileaj,  1541. 

t  Mulier  Angla,  oculista,  vidente  My  Lord  Rich,  filio  Comitis  Warwick,  acu  ape- 
ruit  corneam  supra  pupillam,  et  humorem  Aqueum  exhausit  sive  effluere  sivit,  qui 
turbidus  et  obscurior  factus,  visionem  imminuerat,  ita  ut  aeger  quasi  per  velum  se 
omnia  confuse  cernere  drederet.  Post  humoris  effluxum  oculus  concidit.  Applicata 
remedia,  imperata  quies  in  tenebris  ;  prospectum  inflaramationi.  Aliquot  post  diebus 
postliminio  succrescente  humore  Aqueo,  qui  est  excrementitius,  non  pars  corporis,  et 
qui  reparari  potest ;  intumuit,  sive  repletus  oculi  globus  ;  punctura  ejus  occlusa  et  con- 
solidata,  nulli  remanente  cicatrice.  Restituta  visionis  acies,  et  perfecte  curatus  fuit 
seger.     Praxeos  Mayemianse,  Syntagma,  p.  84.     Londini,  1690. 

t  The  edition  of  Gleize  now  before  me  is  that  of  1812.  Either  the  original  edition, 
published  in  1786,  contains  a  very  diiferent  account  of  the  case  referred  to  in  the  text, 
or  Buckhorn  is  incorrect  in  stating  that  through  the  wound  Gleixe  divided  the  lens 
and  capsule,  that  the  lens  dissolved  in  twenty  days,  and  that  Gleize  adopted  this  as  a 
successful  mode  of  operating.  On  the  contrary,  is  was  depression  which  Gleize  per- 
formed in  the  case  referred  to,  and  he  prefers,  when  the  cataract  is  soft,  that  it  should 
if  possible  be  extracted,  "pour  eviter  la  longueur  de  sa  dissolution." 


536 

this  instance  led  him,  however,  to  recommend  a  similar  mode  of 
operation  in  other  cases  ;  namely,  that  having  dilated  the  pupil  by 
belladonna,  the  operator,  should  make  an  incision  at  the  edge  of 
the  cornea,  introduce  a  needle  and  divide  the  capsule  circularly, 
depress  the  lens  if  hard,  extract  it  if  soft,  but  leave  any  fragments 
which  might  be  detached  from  it,  or  even  the  whole  lens  if  it  could 
neither  be  depressed  nor  extracted,  to  be  dissolved  by  the  aqueous 
humour,  an  event  which  he  says  occupies  twenty  or  thirty  days,  or 
longer.* 

The  honour  of  having  been  the  first  to  propose  a  distinct  method 
of  operating  by  division  through  the  cornea,  appears  to  belong  to 
Conradi,  a  surgeon  at  Nordheira  in  Hanover.  He  at  once  passed 
a  needle,  or  rather  a  small  lancet-shaped  knife,  through  the  cornea, 
opened  the  anterior  hemisphere  of  the  capsule,  and  then  withdrew 
the  instrument,  leaving  the  cataract  to  be  dissolved  ;  an  operation 
which  is  certainly  one  of  the  simplest  yet  proposed  for  the  cure  of 
this  disease,  being  executed  with  a  single  instrument,  and  interest- 
ing only  the  cornea  and  the  capsule.t 

The  operation  of  Conradi  was  quickly  put  to  the  test  in  different 
parts  of  Germany.  In  many  cases  it  was  found  completely  suc- 
cessful ;  but  in  others,  the  punctured  incision  of  the  capsule  healed 
up,  and  thus  the  solution  of  the  cataract  was  interrupted.  This 
led  Buchhorn,  of  Magdeburg,  to  add  two  important  steps  to  the 
operation  of  Conradi ;  namely,  the  division  of  the  lens  as  well  as 
of  the  capsule,  and  the  bringing  forward  of  the  fragments  of  the 
cataract  into  the  anterior  chamber  with  the  flat  side  of  the  needle. + 
The  division  of  the  lens,  and  the  introduction  of  its  fragments  into 
the  anterior  chamber,  hasten  the  solution  of  the  cataract  and  the 
consequent  restoration  of  sight.  The  success,  however,  of  this 
method  depends  chiefly  upon  the  degree  in  which  the  anterior 
hemisphere  of  the  capsule  is  divided.  If  this  part  of  the  operation 
be  so  completely  effected  that  the  remains  of  that  membrane  can- 
not afterwards  unite,  then  the  solution  of  a  cataract  of  ordinary 
consistence  is  certain,  even  should  it  be  left  entire,  and  in  its  natu- 
ral situation. 

Division  through  the  cornea  comprehends  three  periods  ;  viz. 
first,  the  introduction  of  the  needle  ;  secondly,  the  division  of  the 
capsule ;  and  thirdly,  the  division  of  the  lens  and  scattering  of  its 
fragments. 

The  pupil  is  to  be  fully  dilated  by  belladonna. 

The  needle  ought  to  be  considerably  smaller  than  that  used  for 
division  through  the  sclerotica,  as  in  the  present  case  it  has  to  ope- 

*  Nouvelles  Observations  pratiques  sur  les  Maladies  de  i'CEil,  p.  118.  Orleans, 
1812. 

t  Conradi  published  an  account  of  his  n  ode  of  operating  in  1791,  in  the  1st  volume 
of  Arnem inn's  Magazin  fflr  die  Wundarznevkunst. 

X  Buchhorn  de  Keratonyside.  Halae,  1806.  Die  Keratonyxis  eine  neue  gefahr- 
losere  Methode  den  grauen  Staar  zu  operiren  ;  Von  W.  H.  J.  Buchhorn.  Madge- 
burg,  1811.  Buchhorn  was  the  first  who  gave  the  name  of  Keratonyxis,  or  punctio 
cornffi,  to  this  method  of  operating. 


537 

rate  through  the  pupil,  and  often  in  the  eyes  of  infants.  The  edge 
must  be  very  sharp,  the  neck  round,  and  of  such  a  degree  of  in- 
creasing thickness  as  shall  fill  the  wound  made  by  the  bent  or 
lance-shaped  part  of  the  instrument,  and  so  prevent  the  aqueous 
humour  from  escaping. 

1st  Period.  The  needle  is  to  be  passed  through  the  cornea  at 
the  distance  of  not  less  than  one-tenth  of  an  inch  from  the  sclerotica. 
Some  prefer  the  temporal,  others  the  lower  edge.  If  the  temporal 
edge  is  chosen,  the  instrument  can  be  more  conveniently  used  for 
bringing  forward  the  fragments  of  the  divided  lens  into  the  anterior 
chamber.  If  the  inferior  edge  is  preferred,  and  the  operator  chooses 
to  sit  before  the  patient,  the  right  eye  may  be  operated  on  with  the 
right  hand,  and  in  entering  the  needle,  the  instrument  may  be 
supported  on  the  nail  of  the  index  finger  of  the  left  hand,  which 
at  the  same  time  depresses  the  lower  lid,  till  it  has  fairly  entered 
the  anterior  chamber,  which  is  no  small  advantage  for  an  inexpe- 
rienced operator.  In  passing  through  the  cornea,  the  point  of  the 
instrument  is  to  be  directed  towards  the  centre  of  the  pupil,  and  if 
it  is  a  bent  needle  which  is  used,  its  convex  surface  is  to  be  turned 
toward  the  eye. 

2d  Period.  Directing  the  edge  of  the  needle  towards  the  cata- 
ract, the  operator  endeavours  to  reduce  to  minute  fragments  the 
central  portion  of  the  capsule,  in  an  extent  equal  to  the  natural 
size  of  the  pupil.  This  he  performs  partly  by  a  scraping  motion 
of  the  instrument,  partly  by  numerous  touches  of  its  edge  and  point, 
taking  care  not  to  raise  the  capsule  on  the  point  of  the  instrument, 
which,  by  rending  that  membrane  across,  might  give  rise  to  dislo- 
cation of  the  lens,  and  would  at  least  prevent  the  division  from  be- 
ing accomplished  in  a  satisfactory  manner.  Generally  speaking, 
nothing  farther  should  be  attempted  at  a  first  operation.  The  cap- 
sule being  divided,  the  needle  is  to  be  withdrawn. 

3d  Period.  Division  generally  requires  to  be  performed  more 
than  once,  and  in  the  second  and  subsequent  operations,  it  is  the 
breaking  down  of  the  lens  which  is  to  be  chiefly  attended  to,  unless 
at  the  first  operation  the  formation  of  a  sufficient  central  aperture  in 
the  capsule  has  failed.  When  this  has  been  the  case,  the  division  of 
the  capsule  must  be  repeated,  then  the  lens  broken  down  by  cautious 
lateral  movements  of  ihe  needle,  and  the  fragments  brought  forward 
with  the  flat  side  of  the  instrument  into  the  anterior  chamber. 
This  being  accomplished,  the  needle  is  to  be  withdrawn.  As  in 
division  through  the  sclerotica,  the  posterior  hemisphere  of  the  cap- 
sule ought  to  be  spared  as  much  as  possible  ;  and  in  the  operation 
through  the  cornea,  this  can  be  done  more  easily  than  in  division 
through  the  sclerotica. 

After-treaiment.  The  same  as  when  division  through  the  scle- 
rotica has  been  performed. 

Accidents  during  or  after  division  through  the  cornea.     1. 
It  sometimes  happens  that  just  as  the  needle  passes  through  the 
68 


538 

cornea,  the  dilated  pupil  suddenly  contracts.  This  does  not  arise 
from  the  iris  being  touched  with  the  needle,  for  it  takes  place  before 
the  point  of  the  instrtiment  is  fairly  within  the  anterior  chamber. 
After  a  minute  or  two,  the  pupil  generally  expands  again,  so  that 
the  operation  may  be  proceeded  wdth.  If  it  continues  contracted 
after  some  minutes,  the  needle  must  be  withdrawn ;  and  on  some 
future  day,  another  attempt  may  be  made,  giving  the  pupil  every 
chance  of  keeping  dilated,  by  using  the  belladonna  both  on  the 
day  previous  to  the  operation,  and  about  an  hour  before  it  is  per- 
formed, 

2.  Should  the  needle  be  ill  adapted  for  accurately  filling  the 
wound  of  the  cornea,  made  by  the  lance-shaped  or  bent  part  of  the 
needle,  the  aqueous  humour  is  apt  to  escape,  one  of  the  consequences 
of  which  is  that  the  iris  advances  towards  the  cornea,  and  folds 
itself  round  the  needle,  so  that  it  is  difficult,  if  not  impossible,  to 
proceed  with  the  operation.  In  this  case,  the  operator  should  either 
immediately  withdraw  the  needle,  or  merely  open  the  front  of  the 
capsule  by  a  single  scratch  with  the  point  of  the  instrument,  and 
then  withdraw  it,  taking  care  to  supply  himself  with  a  better  nee- 
dle before  attempting  the  operation  a  second  time. 

The  advancement  of  the  iris,  however,  is  not  the  only  bad  con-- 
sequence  of  the  loss  of  the  aqueous  humour  in  this  operation. 
The  lens  also  is  apt  to  start  forward,  and  sometimes  even  bursts 
from  the  capsule.  Left  in  this  state,  the  lens  presses  against  the 
pupil,  and,  if  hard,  may  give  rise  to  severe  inflammation  of  the 
iris,  and  even  of  the  cornea.  Under  these  circumstances,  then,  it 
is  advisable  immediately  to  extract  the  lens  through  a  small  sec- 
tion of  the  cornea. 

3.  The  fluid  cataract  is  to  be  treated  as  has  already  been  recom- 
mended on  other  occasions ;  *  but  the  hard  cataract  cannot  be 
managed  so  easily  as  if  the  needle  had  been  passed  through  the 
sclerotica.  Some  of  the  German  operators  recommend  reclinatioa 
to  be  immediately  performed  when  the  lens  proves  to  be  hard,  but 
I  should  judge  it  better  to  withdraw  the  needle,  and  either  to  delay 
all  farther  proceedings  for  a  time,  or  immediately  to  introduce  the 
instrument  through  the  sclerotica,  push  the  lens  forward  through 
the  pupil,  open  one-third  of  the  circumference  of  the  cornea  and 
extract. 

4.  Division  through  the  cornea  is  sometimes  followed  by  cornei- 
tis,  generally  attended  by  inflammation  of  the  iris.  The  cornea 
loses  its  lustre,  and  its  internal  surface,  probably  from  eflused 
lymph,  sometimes  becomes  of  a  j^ellowish  colour.  The  aqueous 
humour  also  assumes  a  turbid  appearance,  so  that  the  state  of  the 
iris  can  be  discerned  with  difficulty.  As  the  cornea  and  anterior 
chamber  become  clear,  the  iris  is  probably  observed  to  be  retracted, 
the  pupil  irregular,  its  edge  adherent  here  and  there  to  the  rem- 

•  See  pp.  508  and  533. 


539 

nants  of  the  capsule,  and  these  to  be  of  a  whitish  colour,  forming 
a  capsular  secondary  cataract.  It  is  a  very  common  result  of  divi- 
sion, either  through  the  cornea  or  through  the  sclerotica,  that  the 
capsule,  transparent  at  the  time  of  the  operation,  becomes  more  or 
less  of  a  whitish  colour,  requiring  to  be  carefully  removed  out  of 
the  axis  of  vision  by  a  subsequent  operation.  The  bad  effects  of 
inflammation  of  the  cornea,  iris,  and  capsule,  must  be  obviated  as 
much  as  possible  by  blood-letting,  calomel  with  opium,  counter-ir- 
ritation, and  belladonna.  The  attack  is  sometimes  so  acute  as  to 
require  repeated  general  blood-letting.  In  other  cases,  the  in- 
flammation is  comparatively  slight,  continuiiig  for  months,  and 
perhaps  scarcely  attracting  attention,  except  from  those  who  have 
been  put  on  their  guard  against  this  chronic  form  of  corneitis  and 
iritis.* 

If  the  operation  of  division  be  performed  on  the  eyes  of  old  per- 
sons, arthritic  ophthalmia  is  apt  to  follow,  and  will  resist  almost 
every  method  of  cure.  The  pain  of  the  eye  and  head  continues 
unabated,  notwithstanding  depletion,  counter-irritation,  mercury, 
and  opium.  The  patient  gets  little  or  no  rest,  day  or  night. 
The  redness  is  not  intense  ;  there  is  a  bluish-white  ring  very  dis- 
tinct round  the  edge  of  the  cornea  ;  the  lens  becomes  of  a  green 
colour,  and  appears  swollen  ;  and  the  retina  is  soon  rendered  to- 
tally insensible.  In  such  a  case,  it  is  advisable,  merely  as  a  means 
of  relief  from  pain,  to  extract  the  lens  through  a  small  section  of 
the  cornea. 


SECTION  XII. CHOICE  OF  AN  OPERATION  FOR  CATARACT,  IN- 
DICATIONS AND  CONTRA-INDICATIONS  FOR  THE  DIFFERENT 
MODES  OF  OPERATING. 

When  a  case  of  cataract  presents  itself,  which  there  is  no  likeli- 
hood of  relieving  except  by  an  operation,  the  honest  and  intelligent 
practitioner  will  ask  himself.  Is  this  a  case  for  division,  or  ought  I 
to  venture  extraction,  or  ought  I  to  content  myself  with  displace- 
ment ?  He  will  be  guided  in  his  answer,  partly  by  the  kind  of 
cataract  which  is  before  him,  and  the  kind  of  eye  in  which  that 
cataract  exists,  and  partly  by  the  degree  of  confidence  which  he 
has  in  his  own  powers  and  experience  as  an  operator.  So  far  as 
the  dangers  likely  to  accrue  from  the  mere  operations  are  concerned, 
the  following  is  the  order  in  which  I  am  inclined  to  arrange  them, 
placing  the  safest  first,  and  the  most  objectionable  last ;  Division 
through  the  cornea,  division  through  the  sclerotica,  extraction 
through  a  small  section  of  the  cornea,  extraction  through  a  semi- 
circular section  of  the  cornea,  extraction  through  the  sclerotica, 
reclination  through  the  sclerotica,  reclination  through  the  cornea, 
depression  through  the  sclerotica,  depression  through  the  cornea. 

*  See  Schindler  de  Iritide  Chronica  ex  Ceratonyxide.    Vratislavias,  1819. 


540 

I  hold  it  unnecessary,  after  what  has  been  said  in  the  foregoing 
sections,  to  discuss  minutely  the  merits  and  demerits  of  each  of- 
these  operations,  but  the  following  general  remarks  may  not  be  un- 
worthy of  attention. 

I.  As  the  success  of  division  depends  on  the  solution  of  the  frag- 
ments to  which  the  cataract  is  reduced,  and  that  within  a  mode- 
rate space  of  time,  and  without  any  injurious  irritation  of  the  eye, 
this  method  of  operating  is  plainly  contra-indicated  whenever  the 
lens  is  of  hard  or  firm  consistence,  or  the  capsule  greatly  thickened 
or  very  tough.  Such  cataracts  are  either  incapable  of  being  di- 
vided with  safety  to  the  neighbouring  parts,  or  if  divided,  are  in- 
capable of  being  dissolved.  The  cystic  cataract  is  evidently  im- 
proper for  division,  on  account  of  the  thickness  of  the  capsule,  even 
although  the  lens  is  fluid,  as  is  also  that  variety  of  cataract  which 
we  occasionally  meet  with  in  old  persons  in  which  the  central  half, 
or  more  than  the  central  half,  of  the  lens  is  hard,  while  the  super- 
ficial laminae  are  soft  or  reduced  to  the  state  of  a  fluid. 

It  is  only  where  the  lens  is  throughout  caseous  or  fluid,  and  the 
capsule  either  transparent,  or  at  least  not  greatly  thickened,  that 
we  can  with  propriety  have  recourse  to  division.  Hence  it  is,  that 
in  almost  all  cases  of  cataract  in  children  and  young  persons,  this 
is  the  operation  which  is  to  be  preferred,  while  in  old  persons  it 
very  rarely  answers. 

In  the  following  cases,  division  appears  to  be  peculiarly  indi- 
cated. 

1.  When  the  one  eye  is  bhnd  from  cataract,  and  in  the  other 
the  disease  is  merely  incipient.  By  the  time  that  the  cataract  is 
fully  formed  in  the  second  eye,  the  divided  lens  may  already  be 
dissolved  in  the  other. 

2.  In  weakly,  timid,  or  irritable  persons,  and  in  those  who  are 
subject  to  convulsive  or  nervous  diseases.  Extraction  or  displace- 
ment, both  of  which  are  severe  in  comparison  to  this  mode  of  op- 
erating, would  be  improper  in  such  cases. 

3.  When  the  surgeon  is  timid,  and  unaccustomed  to  operate  on 
the  eye.  The  errors  which  such  a  person  is  likely  to  commit  in 
performing  extraction  or  displacement,  may  be  fatal  to  the  patient's 
sight,  but  in  division  he  can  do  comparatively  little  harm,  and  if 
his  first  attempts  fails  to  remove  the  cataract,  the  operation  can 
be  repeated. 

Division  must  be  regarded  as  an  excellent  mode  of  curing  those 
varieties  of  cataract  which  are  susceptible  of  solution  ;  whereas,  if 
the  operator  employs  division  in  cases  unfit  for  this  mode  of  cure, 
disappointment  will  be  the  result,  and  a  false  estimate  will  proba- 
bly be  formed  of  the  merits  which  the  operation  really  possesses. 
If  we  have  recourse  to  division  for  the  removal  of  the  hard  cataract 
of  old  people,  we  shall  not  merely  waste  time,  but  expose  our  pa- 
tients to  such  evil  consequences  as  may  unfit  them  from  deriving 
advantage  from  any  other  mode  of  operating. 


541 

With  regard  to  the  comparative  merits  of  division  through  the 
cornea  or  through  the  sclerotica,  as  the  cornea  is  insensible,  the 
former  operation  is  the  less  painful,  there  is  of  course  no  danger 
of  injuring  the  ciliary  processes  or  retina  when  the  needle  passes 
through  the  cornea,  the  anterior  capsule  is  also  certain  of  being 
more  or  less  completely  divided  in  this  method,  while  the  posterior 
capsule  is  more  likely  to  escape  being  destroyed  than  in  the  opera- 
tion through  the  sclerotica,  the  hyaloid  membrane  is  left  entire, 
and  the  sensibility  of  the  retina  is  less  liable  to  be  endangered  by 
the  violence  done  to  the  neighbouring  textures.  These  advanta- 
ges, however,  are  counterbalanced  by  the  danger  of  bruising  the 
iris  with  the  needle  passed  through  the  cornea,  the  liability  of  cor- 
neitis  to  occur  after  this  mode  of  operating,  the  difficulty  of  satisfac- 
torily dividing  the  lens  and  separating  its  fragments,  and  should 
the  lens  unexpectedly  prove  hard,  the  difficulty  of  bringing  it  for- 
ward through  the  pupil  for  extraction.  For  these  reasons,  division 
through  the  sclerotica  ought  in  general  to  be  preferred. 

II.  That  extraction  is  the  only  proper  mode  of  removing  a  hard 
€ataract,  is  an  assertion,  of  the  truth  of  which  those  who  have  had 
any  considerable  experience  in  the  treatment  of  eye-diseases,  and 
have  been  able  to  think  for  themselves  on  the  subject,  are  as  firmly 
convinced  as  they  are  that  soft  cataract  may  safely  and  satisfacto- 
rily be  cured  by  division.  To  attempt  the  cure  of  hard  cataract 
by  division,  would  be  worse  than  useless.  When  no  particular 
contra-indication,  therefore,  exists  to  extraction,  we  have  recourse 
to  that  operation  ;  and  the  only  points  remaining  for  our  consid- 
eration are  the  contra-indication s  to  extraction  which  may  exist 
even  when  the  cataract  is  hard,  and  the  comparative  advantages 
of  a  large  or  small  section  of  the  cornea. 

The  following  are  some  of  the  chief  contra-indications  to  ex- 
traction through  a  semicircular  incision  of  the  cornea.  They  of 
course  may  be  regarded  so  far,  as  indications  either  for  extraction 
through  a  small  section,  or  for  displacement, 

1.  When  the  cornea  is  flat,  the  iris  convex,  the  eyeball  small, 
and  deep  in  the  orbit,  or  the  space  between  the  lids  very  narrow, 
it  is  difficult,  and  often  impossible,  to  make  a  semicircular  section 
of  the  cornea  in  the  usual  manner. 

2.  A  broad  arcus  senihs  has  been  stated  as  an  objection  to  ex- 
traction, on  account  of  the  difficulty  with  which  the  incision  unites, 
if  it  be  carried  through  the  opaque  portion  of  the  cornea.  This 
alleged  difficulty  of  union,  however,  does  not  always  occur;  for  I 
have  seen  the  section  of  the  cornea  through  an  arcus  senilis  heal 
with  perfect  facility. 

3.  The  existence  of  adhesions  either  between  the  cornea  and 
iris,  or  between  the  iris  and  the  crystalline  capsule,  generally  debar 
the  operation  of  extraction ;  for  in  the  former  case,  it  is  not  likely 
that  the  section  could  be  executed  without  dividing  the  iris,  while 
in  the  latter,  the  division  of  the  capsule  and  exit  of  the  lens  are 
prevented. 


542 

4.  If  the  pupil  is  very  small,*  and  even  when  under  the  in- 
fluence of  belladonna  dilates  to  an  inconsiderable  extent,  the  last 
mentioned  objection  will  still  occur  to  prevent  us  from  attempting 
extraction. 

5.  A  fluid  state  of  the  vitreous  humour  is  a  very  sufficient  ob- 
jection to  the  ordinary  operation  of  extraction,  which  ought  there- 
fore never  to  be  attempted  unless  the  eyeball  presents  to  the  touch 
its  natural  degree  of  firmness.  If  soft  and  boggy,  the  vitreous  fluid 
is  deficient  in  quantity,  and  the  hyaloid  membrane  in  general  de- 
stroyed ;  but  much  more  frequently  a  dissolved  state  of  the  hyaloid 
membrane  is  attended  by  a  superabundant  quantity  of  the  vitreous 
fluid,  and  an  extraordinary  degree  of  firmness  of  the  eyeball.  In 
either  of  these  cases,  the  cataract,  clinging  b)^  the  edge  of  the  cap- 
sule to  the  circumference  of  the  ciUary  processes,  may  easily  be 
displaced  by  the  needle.  The  least  touch  is  in  general  sufficient 
to  make  it  sink  to  the  bottom  of  the  eye,  and  even  without  any 
operation,  a  natural  displacement  of  this  sort  sometimes  occurs,  to 
the  astonishment  and  delight  of  the  patient.t  The  restoration  of 
sight  in  such  cases,  whether  effected  by  the  needle,  or  by  a  natural 
solution  of  the  connexion  between  the  cataract  and  the  ciliary  pro- 
cesses, is  seldom  of  long  continuance.  On  looking  into  the  eye, 
the  cataract  is  seen  bobbing  about  in  the  vitreous  fluid,  the  iris,  if 
not  previously  tremulous,  now  becomes  so,  and  in  the  space  of  a 
few  weeks  or  months  the  retina  is  found  to  be  insensible.  This 
is  the  natural  history  of  glaucoma.  Once  on  touching  such  a  cata- 
ract with  the  needle,  I  observed  that  it  separated  from  the  cihary 
circle  except  toward  the  nose,  where  it  continued  to  hang  as  if  on  a 
hinge.  When  the  patient  looked  upwards  he  saw  tolerably  well, 
and  could  read  the  names  above  the  shop  doors  with  facility,  for 
in  such  a  position  of  his  head  the  cataract  floated  back  into  the 
vitreous  fluid  and  left  the  pupil  clear,  but  the  instant  he  attempted 
to  examine  any  object  which  required  him  to  lean  forward,  such 
as  reading  a  book  lying  on  a  table  before  him,  he  saw  none,  the 
cataract  moving  forward  and  shutting  the  pupil  exactly  like  a  door 
or  lid.  This  patient  continued  for  some  time  to  show  himself  at 
the  Eye  Infirmary,  but  at  his  last  visit  he  was  totally  blind,  the 

*     Myosis.  t  Dominus  Packer  passus  est  in  oculo  sinistro  cataractam  con- 

firmatissimara  ad  minus  per  annos  23,  quam  albissimam,  satis  compactam  et  maturam 
acu  deturbandam  ssepius  suasi ;  un^  nocte,  sine  ulla  causa  externa,  evanuit  suffusio, 
et,  licet  confuse,  mane  ccepit  et  lucem  aspicere  et  colores  agnoscere.  Venit  ad  me,  et 
oculum  ostendit  purum,  lucidum  sine  ulla  humorum  perturbatione,  obscuritate  aut  con- , 
fusione.  Pupilla  minor  tamtum  fuit,  quae  tamen  clause  altero  oculo  dilatabatur.  Non 
credo  fuisse  dissipatum  istud  coagulum,  sed  pondere  forsan  ab  uvea  divulsam  fundum 
petiisse  aquei  humoris  eo  loci  ubi  ab  acu  separata  cataracta  deprimitur  et  subsidit. 
Forsan  ascendet  denuo,  ut  saepe  contingit  in  cataractis  male  depressis  et  locatis  ab 
operatore,  nisi  forsan  substantia  crassior  et  gravis  elevationem  impediat. 

Elapsis  diebus  15,  ad  me  rediit,  ostendit  oculum  dariorem,  el  facile  de  omnibus 
objectis  visibilibus  potuit  pronunciare.  Dixit  tamen  uxorem  aliquoties  vidisse  partem 
cataractae  denuo  ascendentem  ad  pupillam,  quae  valid^.  narium  emunctione  iliico  ima 
iterum  petiit.  Proculdubio  recurret,  neque  enim  absumi  potest.  Praxeos  Mayernianae 
Syntagma,  p.  83.    Londini,  1690. 


543       . 

lid  had  separated  from  its  hinge,  the  pupil  was  clear,  the  cataract 
floated  behind  the  lower  edge  of  the  pupil,  the  iris  was  tremulous, 
the  eyeball  very  hard,  and  the  retina  insensible.  All  such  cases 
are  attended  by  deficiency  of  the  pigmentura  nigrum,  they  begin 
with  hardness  of  the  eye,  and  end  sooner  or  later  in  total  blind- 
ness. When  I  know,  then,  that  glaucoma  has  preceded  cataract, 
or  when  I  find  the  eye  preternaturally  firm,  I  extract  through  a 
small  section,  as  the  only  mode  of  operating  which  is  safe  and 
proper  under  such  circumstances. 

6.  When  the  eyes  are  exceedingly  restless,  affected  perhaps  with 
convulsive  motions,  or  when  the  patient  is  under  the  influence  of 
excessive  fear,  or  exhibits  an  extreme  want  of  docility,  the  ordinary 
operation  of  extraction  is  out  of  the  question.  It  has  sometimes 
happened  that  under  circumstances  such  as  these,  even  displace- 
ment has  with  great  difiiculty  been  effected.  Thus  in  Mr.  Ward- 
rop's  first  attempt  to  operate  on  James  Mitchell,  the  blind  and  deaf 
boy,  then  about  15  years  of  age,  the  patient  at  first  yielded  readily, 
and  allowed  himself  to  be  placed  and  held  on  the  table.  The  un- 
easiness, however,  occasioned  by  the  pressure  necessary  to  keep 
the  eyeball  steady  and  the  lids  open,  seemed  to  overcome  his  reso- 
lution, and  his  exertions  became  so  violent,  that  it  was  quite  im- 
possible to  secure  even  his  head. 

A  second  attempt  was  made  the  day  following,  more  precautions 
being  taken  to  secure  him,  but  so  violent  were  his  exertions  and 
cries,  and  so  irascible  did  he  become,  that  all  present  were  glad  to 
to  relinquish  their  posts.  Some  days  after,  a  wooden  box,  the 
sides  of  which  moved  on  hinges,  was  folded  round  his  body,  and 
fixed  by  circular  i*opes  ;  and  in  this  way,  notwithstanding  a  power- 
ful resistance,  he  was  placed  on  a  table  and  kept  quite  steady.  Mr. 
Wardrop  had  given  up  all  hopes  of  extracting  the  cataract,  and  de- 
termed  to  try  couching.  Much  difficulty  was  found  in  holding  open 
the  lids,  and  keeping  the  globe  of  the  eye  steady.  As  soon,  how- 
ever, as  the  needle  touched  the  eye  he  remained  quite  steady,  and 
his  dreadful  screaming  ceased.  With  the  sharp  edge  of  the  instru- 
ment, Mr.  Wardrop  cut  through  the  anterior  portion  of  the  capsule, 
and  with  its  point  dragged  the  lens  from  behind  the  pupil.  On 
depressing  the  point  of  the  needle,  the  lens  remained  out  of  view 
except  a  small  portion  of  its  inferior  edge.  On  the  fourth  day  after 
the  operation,  the  lens  was  found  to  have  changed  its  place,  and 
could  be  again  distinguished  covering  about  one-fourth  of  the  upper 
edge  of  the  pupil.* 

III.  With  regard  to  the  comparative  merits  of  a  large  or  small 
section  of  the  cornea,  it  must  be  acknowledged,  that  while  no  ope- 
ration disturbs  the  internal  textures  of  the  eye  less  at  the  moment 
of  performance  than  dexterously  executed  extraction   through  a 

*  Wardrop's  History  of  James  Mitchell,  pp.  27,  32.  London,  1813.  From  the  ex- 
pressions employed  by  Mr.  W.,  one  might  almost  be  led  to  suppose  that  the  cataract 
had  been  pressed  upwards,  rather  than  downwards,  in  the  operation. 


544 

gemicircular  incision,  none  endangers  the  safety  of  the  eye  so 
much  after  the  operation  is  finished.  Extraction  through  a  small 
section,  on  the  other  hand,  causes  more  disturbance  within  the  eye 
at  the  moment  of  operation,  but  exposes  the  organ  to  much  less  risk 
after  the  cataract  is  removed.  Extraction  through  a  small  section, 
although  it  requires  fully  as  much  caution,  demands  less  dexterity, 
endangers  the  iris  less,  is  rarely  attended  by  any  considerable  ejec- 
tion of  vitreous  humour,  is  scarcely  ever  followed  by  protrusion  of 
the  iris,  rarely  gives  rise  to  violent  inflammation,  and  cannot  pro- 
duce so  deforming  or  so  mischievous  a  cicatrice.  Fragments  of  the 
lens  are  apt  to  be  left  behind,  and  the  hning  membrane  of  the 
cornea  is  sometimes  excited  to  inflammation,  especially  when  the 
operation  has  been  clumsily  done,  but  there  is  no  denying,  that, 
after  extraction  through  a  small  section,  the  operator  sends  his  pa- 
tient to  bed  with  feehngs  of  far  less  apprehension  for  the  coming 
result,  than  after  extraction  through  a  semicircular  incision. 

IV.  The  principle  on  which  are  founded  the  operations  of  dis- 
placement, is  essentially  bad.  As  well  might  we  expect  to  be  able 
to  lodge  an  entirely  foreign  body  within  the  eye,  and,  yet,  that  con- 
tinued irritation  should  not  take  place,  disorganization  not  follow 
of  the  delicate  textures  with  which  it  remained  in  contact,  and  the 
function  of  the  organ  not  be  interrupted,  as  that  the  lens  could  be 
pressed  into  the  vitreous  humour,  and  lie  there  close  to  the  retina, 
and  the  eye  continue  healthy  and  vision  be  preserved.  Reclination 
and  depression  are  to  be  thought  of  only  when  some  insuperable 
objections  exist  to  division  and  extraction.  I  assign  them  this  low 
rank  in  the  scale,  not  because  the  lens  is  apt  to  reascend  after  be- 
ing displaced,  for  that  I  consider  as  in  general  the  most  favourable 
event  which  can  possibly  happen,  from  the  chance  it  gives  of  the 
cataract  being  dissolved  after  its  reascension  ;  but  because  chronic 
inflammation  within  the  eye,  dissolution  of  the  hyaloid  membrane, 
and  amaurosis,  are,  I  believe,  the  almost  invariable  results  of  a 
cataract  of  any  considerable  bulk  continuing  in  the  unnatural  situ- 
ation assigned  to  it  by  depression  or  reclination. 


SECTION  XIII. — 'SECONDARY  CATARACT. 

Secondary  cataract  consists  either  in  some  portion  of  the  cataract 
which  had  existed  previous  to  the  operation,  but  which  had  been 
but  imperfectly  removed  by  it,  or  in  some  new  production  which 
first  began  to  exist  after  the  operation.  Secondary  cataract  may 
be  true,  or  spurious,  or  mixed.  It  may  be  a  piece  of  lens,  a  piece 
of  capsule,  a  lymphatic  effusion,  or  a  combination  of  these. 

1.  With  regard  to  lenticular  fragments  remaining  behind  the 
pupil  after  any  of  the  operations  for  cataract,  if  productive  of  no 
apparent  irritation,  it  is  the  best  practice  to  wait  for  some  time,  and 
give  them  a  chance  of  being  dissolved  by  the  aqueous  humour. 


545 

Sometimes  even  an  entire  lens,  which  has  re-ascended,  may  be 
allowed  to  remain,  and  will  gradually  be  removed  by  absorption. 
In  the  meantime,  external  causes  of  irritation  are  to  be  carefully 
guarded  against,  and  the  pupil  kept  dilated  by  belladonna.  Should 
solution  not  take  place  within  a  reasonable  space  of  time,  we  have 
our  choice  either  to  extract  the  lens  through  a  small  section,  or 
displace  it. 

2.  Capsular  secondary  cataract  rarely  follows  the  operations  of 
displacement,  especially  rechnation,  the  capsule  being  in  general 
removed  from  the  axis  of  vision  along  with  the  lens ;  but  after  ex- 
traction, and  still  more  after  division,  this  sort  of  secondary  cataract 
is  very  apt  to  occur. 

If  the  anterior  hemisphere  of  the  capsule  has  been  somewhat 
opaque  before  extraction  was  performed,  and  the  operator  has  not 
carefully  removed  this  opaque  membrane  when  he  extracted  the 
lens,  or  if  with  a  transparent  capsule  the  second  period  of  the  ope- 
ration has  been  carelessly  performed,  and  even  the  slightest  degree 
of  internal  inflammation  supervenes  after  extraction,  secondary  cap- 
sular cataract  will  certainly  occur,  and  is  not  unHkely  to  be  so  com- 
plete and  dense,  as  almost  entirely  to  defeat  the  object  of  the  opera- 
tion. If  iritis  also  occurs  after  the  operation,  the  remnants  of  the 
capsule  not  only  become  white,  and  unite  together,  but  they  ad- 
here to  the  iris,  the  pupil  becomes  small  and  angular,  and  although 
immediately  after  the  exit  of  the  lens-  the  patient  distinguished 
objects  with  tolerable  precision,  probably  a  mere  perception  of  light 
and  shadow  will  now  be  retained. 

It  is  difficult  to  prevent  the  formation  of  capsular  secondary  cata- 
ract after  the  operation  of  division.  If  the  anterior  capsule  be  merely 
rent  across  by  the  needle,  or  stript  in  one  piece  from  the  front  of 
the  lens,  it  is  very  apt  to  heal  up  again  and  to  become  opaque,  so 
that  it  both  prevents  the  process  of  solution  from  going  on,  and 
forms  itself  a  new  obstacle  to  vision. 

The  capsule  in  the  transparent  state  is  easily  divided  into  shreds, 
but  it  is  otherwise  after  it  has  become  opaque  and  thickened  by 
inflammation.  It  is  then  so  tough  and  elastic,  that  it  is  almost 
impossible  to  divide  it ;  we  may  carry  it  on  the  point  of  the  needle 
almost  to  the  bottom  of  the  vitreous  humour,  whence  it  instantly 
springs  up  again  to  its  former  situation.  To  form  a  sufficient 
central  aperture  in  such  a  capsule  is  next  to  impossible.  It  may 
sometimes  be  gathered  round  the  curved  needle,  separated  from  its 
connexions,  and  depressed  ;  but  it  seldom  remains  long  in  its  new 
situation.  In  the  natural  state,  and  even  after  it  has  become 
opaque,  the  capsule  is  of  less  specific  gravity  than  the  aqueous 
humour  or  the  vitreous  fluid,  and  hence  it  tends  always  to  float  up 
into  the  pupil,  a  fact  which  should  be  borne  in  mind,  as  well  in 
the  ordinary  operation  of  division,  as  in  attempts  to  depress  a  sec- 
ondary capsular  cataract.  A  piece  of  much  thickened  capsule,  if 
completely  insulated,  will  sink,  but  if  still  connected  with  a  consid- 
69 


546 

erable  portion  which  is  not  thickened,  the  whole  will  float.  Hence 
the  propriety  of  dividing  the  capsule  rather  from  below  than  from 
above,  in  order  that  if  any  shreds  remain  in  connexion  with  the 
circumference  of  the  capsule,  they  may  be  attached  near  its  upper 
rather  than  its  lower  edge,  and  thus  float  out  of  the  axis  of  vision. 

The  most  satisfactory  mode  of  removing  capsular  secondary 
cataract  is  through  a  small  section  of  the  cornea,  as  already  de- 
scribed at  page  525.  In  this  way,  I  succeeded  on  one  occasion 
in  removing  the  whole  capsule,  forming  an  entire  bag,  the  centre 
of  the  anterior  hemisphere  being  thickened  and  almost  cartilaginous^ 
while  the  rest  of  the  capsule  was  transparent.  The  lens  had  been 
removed  some  years  before  by  absorption.* 

3.  As  for  spurious  secondary  cataract,  that  which  arises  from  the 
effusion  of  coagulable  lymph,  in  consequence  of  iritis,  is  the  most 
frequent.  The  pupil  is  much  contracted,  perhaps  almost  closed, 
and  adheres  to  the  remains  of  the  capsule  ;  and  the  only  method 
of  restoring  vision  is  to  form  an  artificial  pupil,  in  one  or  other  of 
the  ways  hereafter  to  be  described. 


SECTION  XIV. CATARACT-GLASSES. 

The  loss  of  the  crystalline  lens,  although  it  must  necessarily 
produce  a  considerable  diminution  in  the  refractive  power  of  the 
eye,  appears  to  affect  still  more  the  faculty  which  this  organ  pos- 
sesses, in  the  natural  state,  of  accommodating  itself  to  the  different 
distances  of  objects,  by  changing  its  focal  distance.  These  defects 
we  endeavour  to  remedy  by  the  use  of  doubk-convex  or  plano- 
convex glasses  of  different  foci.  Those  generally  employed  are  of 
2^  inches  focus  for  reading  or  observing  minute  objects  near  at 
hand,  and  of  4J  inches  for  viewing  distant  objects.  These  glasses 
are  employed  for  the  purpose  of  rendering  the  vision  of  those  wha 
have  been  operated  on  for  cataract,  as  distinct  and  perfect  as  pos- 
sible ;  for  there  is  a  distinction,  perhaps  not  a  very  accurately  ex- 
pressed one,  admitted  by  opticians  between  distinct  and  perfect 
vision.  Cataract  patients  after  operation  often  possess  the  former^ 
but  never  the  latter.  They  discern  objects  placed  at  a  certain  dis- 
tance with  tolerable  clearness,  and  even  at  other  distances  than 
that  at  which  they  see  best,  still  discein  objects,  being  enabled  to 
do  this  chiefly  from  the  changes  which  take  place  in  the  size  of 
the  pupil  according  as  the  object  viewed  is  more  or  less  distant ;  but 
they  are  totally  deprived  of  the  control  over  the  refractive  powers 
of  the  eye,  which  this  organ  possesses  in  the  natural  state,  and 
which  depends  either  on  a  change  of  place  in  the  lens,  a  change 
of  figure,  or  both.  From  inattention  to  the  above  distinction,  sev- 
eral authors  of  high  name  have  fallen  into  tlie  error  of  supposing 

"*  See  Gibson's  Practical  Observations  on  the  Formation  of  ah  Artificial  Pupil,  &c. 
p.  117.    London,  1811. 


547 

that  the  eye  still  retained  the  power  of  changing  its  focal  distance, 
after  being  deprived  of  the  crystaUine  lens. 

Not  only  do  patients  who  have  been  operated  on  for  cataract  see, 
with  various  degrees  of  distinctness,  and  at  different  distances, 
without  the  aid  of  any  glass,  or  with  one  glass  only  for  all  distances, 
the  changes  in  the  size  of  the  pupil  assisting  them  much  in  doing 
so,  but  their  sight  is  capable,  by  exercise,  of  very  considerable  im- 
provement. 

Haller  mentions  the  case  of  a  nobleman  who  appears  immedi- 
ately after  the  cataract  was  removed  from  the  axis  of  vision,  to 
have  seen  distinctly  at  various  distances.*  Miss  H.,  a  young  lady 
of  about  20,  whose  vision  Dr.  Young  examined,  used  for  distant 
objects  a  glass  of  4^  inches  focus,  and  wuth  this  she  could  read  as 
far  off  as  12  inches,  and  as  near  as  5.  Hanson,  a  carpenter,  aged 
63,  who  had  had  a  cataract  extracted  a  few  years  before,  also  ex- 
amined by  Dr.  Young,  saw  well  to  work  with  a  lens  of  2f  inches 
focus,  and  could  read  at  8  and  at  15  inches,  but  most  conveniently 
at  11.  Mrs.  Maberly,  aged  about  30,  who  had  had  both  lenses 
extracted,  walked  wnthout  glasses,  and,  with  the  assistance  of  a 
lens  of  about  4  inches  focus,  could  read  and  work  with  ease.t 

The  following  is  a  good  example  of  the  capabiUty  for  improve- 
ment which  the  eye  possesses  after  removal  of  the  crystalline  lens. 
Sir  William  Adams  operated  on  a  postilion,  who  had  been  blind 
nine  years  in  one  eye,  and  three  in  the  other.  Both  cataracts  were 
removed  by  division,  and  when  the  patient  resumed  his  employ- 
ment as  a  postilion,  he  was  from  necessity  obliged  to  wear  specta- 
cles, not  being  able  even  to  walk  without  them  ;  but  finding  that 
his  passengers  were  frequently  apprehensive  of  their  safety,  from 
being  driven  by  a  person  requiring  spectacles,  he  by  degrees  left 
them  off  altogether  in  the  day,  and  in  the  course  of  twelve  months 
could  drive  quite  as  well  without  as  with  them.t 

In  all  these,  and  similar  instances  of  distinct  and  improving 
vision  after  the  removal  of  the  crystalline  lens,  the  use  of  the  op- 
tometer, §  would  at  once  demonstrate  that  perfect  vision  was  want- 
ing, or  in  other  words,  that  the  eye  had  lost  all  control  over  its  re- 
fractive powers. 

The  too  hasty  employment  of  cataract-glasses  after  the  most 
successful  operation,  may  soon  bring  the  eye  to  a  state  of  weakness 
which  will  render  it  unfit  even  for  those  employments  which  re- 
quire but  a  moderate  degree  of  sight.     No  cataract-glasses  ought 

*  Et  lente  ob  cataractam  extracta  "vel  deposita  oculum  tamen  ad  varias  distantias 
"videre,  ut  coram  in  nobili  viro  video  absque  ullo  experimento,  quo  earn  facultatem  re- 
cuperaverit.  Et  sienim  tunc  ob  diinlnutas  vires,  quag  radios  uniunt,  seger  lente  vitrea 
opus  habet,  eadem  tamen  lens  in  omni  distantia  sufficit.  Elementa  Physiologise, 
Tom.  V.  Lib.  xvi.  Sect.  iv.  §  25,  p.  514.    Lausannae,  1763. 

T  On  the  Mechanism  of  the  Eye,  by  Thomas  Young,  M.  D.  Philosophical  Trans- 
actions for  1801,  p.  65. 

t  Journal  of  Science  and  the  Arts,  Vol.  ii.  p.  409.     London,  1817. 

§  See  Porterfield's  Treatise  on  the  Eye,  Vol.  i.  p.  434.  Edinburgh,  1759.  Philo- 
sophical Transactions  for  1801,  pp.  34^  64 


548 

to  be  given  to  a  patient  so  long  as  his  vision  appears  to  be  improv- 
ing without  their  use.  This  generally  continues  to  be  the  case 
for  at  least  two  months  after  the  operation.  If  we  allow  our  patient 
to  use  cataract-glasses  during  this  period,  he  will  no  doubt  be  very 
glad  to  find  that  he  can  return  immediately  to  almost  all  his  ordi- 
nary pursuits  ;  but  he  will  soon  begin  to  observe  that  he  does  not 
see  so  well  as  he  did,  and  this  he  will  probably  remedy  by  a  new 
pair  of  glasses  of  greater  convexity,  and  consequently  of  greater 
magnifying  power  than  those  which  he  first  employed.  He  will 
go  on  in  this  way,  changing  his  glasses  as  his  power  of  vision  be- 
comes less,  till  at  last  he  ends  in  finding  none  which  enable  him 
to  see  so  well  as  he  did  vi'ith  those  which  he  first  employed.  On 
the  other  hand,  if  our  patient  does  not  begin  to  try  cataract-glasses 
till  he  has  completely  recovered  from  the  operation,  and  the  eye  has 
as  much  as  possible  habituated  itself  to  the  absence  of  the  crystal- 
line humour  ;  if  he  then  select  proper  glasses,  and  use  them,  for  a 
while,  only  occasionally,  his  sight  will  still  continue  to  improve,  and 
his  first  glasses  will  probably,  if  he  be  an  old  man,  serve  him  all 
his  life,  and  if  he  be  a  man  of  30  or  40,  he  will  not  require  to 
change  them  till  he  be  50  or  60.  He  will  be  able  to  return  to  the 
finest  kind  of  work  in  which  he  had  been  employed,  such  as  draw- 
ing, or,  if  the  person  be  a  female,  to  sewing,  and  the  like. 

The  best  test  of  a  cataract-glass  is  that  it  enables  the  person  to 
see  objects  distinctly  when  placed  at  that  distance  at  which  he 
could  see  them  before  he  became  affected  with  cataract.  Some- 
times the  two  eyes  are  found  after  operation  to  have  different  points 
of  vision,  so  that  it  is  necessary  to  select  two  glasses  of  different 
powers. 

It  is  said,  that  those  who  have  been  short-sighted  previous  to 
the  formation  of  cataract,  can,  after  a  successful  operation,  usually 
lay  aside  their  concave  glasses,  without  having  occasion  for  any 
others ;  and  that  some  still  require  even  concave  glasses  after  the 
operation  for  cataract,  but  less  concave  of  course  than  those  which 
they  formerly  used. 


CHAPTER  XY. 
ARTIFICIAL  PUPIL, 


SECTION  I. INTRODUCTORY  VIEW  OP  THE  METHODS  OF  FORM- 
ING AN    ARTIFICIAL    PUPIL. 

I.  The  first  attempt  to  restore  vision,  in  cases  in  which  the  natu- 
ral pupil  had  closed,  or  at  least  the  first  that  was  accurately  des- 
cribed, was  made  by  Cheselden,  some  time  previous  to  1728.  In 
that  year,  he  published  a  short  account  of  two  cases,  in  which  the 


549 

natural  pupil  having  closed  after  the  operation  of  couching,  he 
formed  an  artificial  pupil.  He  did  this  by  introducing  a  small 
one-edged  knife  or  needle,  through  the  temporal  side  of  the  sclero- 
tica, and  through  the  iris  into  the  anterior  chamber  ;  he  then  turned 
the  cutting  edge  of  the  instrument  towards  the  iris,  and  as  he 
withdrew  the  knife,  divided  the  iris  transversely,  so  as  to  leave  an 
incision  in  that  membrane,  or  an  artificial  pupil,  extending  to  two- 
thirds  of  its  diameter.  In  his  first  case,  he  formed,  the  artificial 
pupil  above  the  centre  of  the  iris  or  place  of  the  natural  pupil,  be- 
cause he  did  not  know  how  low  he  might  have  lodged  the  cataract 
in  the  operation  of  couching,  which  had  led  to  the  closure  of  the 
natural  pupil.  In  his  second  case,  for  what  reason  he  does  not 
mention,  he  formed  the  artificial  pupil  below  the  middle  of  the  iris. 
His  account  of  th«  whole  is  so  brief,  that  we  are  left  in  doubt  how 
far  the  first  patient  recovered  sight.  The  second,  he  states,  thought 
every  object  at  first  farther  from  him  than  it  was  in  reality,  but 
soon  learned  to  judge  the  true  distance.* 

Such  was  the  original  method  of  forming  an  artificial  pupil.  As 
other  methods  have  since  been  invented,  we  may  distinguish  this 
as  an  artificial  j)ujpil  hy  incision. 

II.  In  the  hands  of  the  first  Wenzel,  Cheselden's  operation 
failed,  and  this  led  him  to  invent  another  method  of  opening  up  an 
artificial  passage  for  the  rays  of  hght  through  the  iris,  in  cases  simi- 
lar to  those  in  which  Cheselden  had  operated,  namely,  closed  pupil 
after  an  operation  for  cataract.  He  first  pierced  the  cornea  with 
the  point  of  the  extraction-knife,  exactly  in  the  same  manner  as  in 
the  operation  of  extraction.  When  the  point  of  the  instrument  had 
arrived  near  the  centre  of  the  iris,  he  plunged  it  through  that  mem- 
brane, then  carrying  the  handle  of  the  instrument  backward,  brought 
out  its  point  through  the  iris  on  the  nasal  side  of  the  contracted 
pupil,  and  through  the  cornea  exactly  as  in  the  operation  of  extrac- 
tion. Carrying  ihe  knife  onwards,  hs  divided  at  once  both  the  iris 
and  the  cornea,  only  that  he  necessarily  completed  the  semicircular 
section  of  the  former  before  that  of  the  latter.  He  then  introduced 
a  small  pair  of  scissors  through  the  incision  of  the  cornea,  and  cut 
off  the  flap  of  the  iris.t  This,  then,  is  what  we  term  an  artificial 
pupil  hy  excision. 

III.  The  facts  that  sometimes  even  a  slight  blow  on  the  eye 
will  separate  a  portion  of  the  circumference  of  the  iris  from  the 
choroid,  that  in  operations  with  the  needle  similar  separations  are 
apt  to  happen,  and  that  the  false  pupils,  as  they  may  be  called, 
which  are  thus  formed,  often  continue  permanently  open,  have 

*  Philosophical  Transactions  for  1728,  Vol.  xxxv.  p.  451.  The  mistakes  into 
which  Haller,  Wenzel,  Janin,  Guthrie,  and  others,  have  fallen,  regarding  Cheselden's 
cases,  must  have  arisen  entirely  from  their  neglecting  to  read  with  attention  the  ac- 
count which  he  has  given  of  them.  The  last  mentioned  author,  who  published  on 
Artificial  Pupil  in  1819,  gravely  tells  us  that  Cheselden  "does  not  seem  to  have  per- 
formed the  operation  on  the  person  whose  history  he  relates  ! " 

t  Traite  de  la  Cataracte.    Paris,  1786. 


550 

suggested  to  different  operators  the  idea  of  a  third  method  of  form- 
ing an  artificial  pupil.  Scarpa,  for  instance,  having  passed  the 
needle  through  the  temporal  side  of  the  sclerotica,  advanced  its 
point  as  far  as  the  upper  part  of  the  nasal  margin  of  the  iris,  which 
he  pierced,  so  that  the  point  of  the  needle  became  just  perceptible 
in  the  anterior  chamber,  close  to  the  edge  of  the  cornea.  He  then 
with  the  needle  pressed  upon  the  iris  from  above  downwards  and 
from  within  outwards,  so  that  a  portion  of  its  edge  might  be  separ- 
ated from  the  choroid.  Placing  the  point  of  the  needle  upon  the 
inferior  aogle  of  the  commenced  fissure,  at  the  same  time  drawing 
the  iris  towards  the  temple,  he  continued  the  pressure  till  the 
separation  was  of  sufficient  extent.  Scarpa  first  employed  a 
straight  needle,  but  afterwards  recommended  one  which  was  bent, 
as  better  calculated  for  the  formation  of  this  artificial  pu'pil  hy 
separation.^ 

There  are  three  kinds  of  operation,  then,  for  the  formation  of  an 
artificial  pupil,  viz.  incision,  excision,  and  separation ;  and  all 
three  were  invented  for  the  purpose  of  restoring  vision,  in  cases  in 
which  the  natural  pupil  had  closed  after  an  operation  for  cata- 
ract. There  are  other  cases,  however,  in  which  the  formation  of 
an  artificial  pupil  becomes  necessary ;  and  as  an  example  of  these, 
I  may  mention  opacity  of  the  centre  of  the  cornea.  Suppose  that 
the  central  portion  of  the  cornea,  to  the  extent  of  one-fifth  of  an 
inch  in  diameter,  is  covered  by  a  dense  leucoma,  even  although  the 
natural  pupil  is  open  and  movable,  and  the  iris  perfectly  health)'', 
the  patient  will  be  deprived  of  any  useful  degree  of  sight.  If  he 
turns  his  back  to  the  light,  indeed,  he  may  perhaps  see  a  little  past 
the  edge  of  the  speck,  he  may  also  discern  objects  obscurely  in  the 
twilight,  when  the  pupil  dilates,  in  consequence  of  the  moderate 
light  to  which  the  eye  is  exposed  ;  but  in  bright  light  he  sees  no- 
thing. We  sometimes  find  that  artificial  dilatation  of  the  pupil  by 
belladonna  suffices  in  such  a  case  to  restore  a  considerable  share  of 
useful  vision.  I  have  known  patients  affected  with  partial  opacity 
of  the  cornea,  continue  for  years  the  daily  application  of  a  filtered 
solution  of  belladonna,  for  the  purpose  of  dilating  the  pupil,  so  that 
the  light  might  enter  the  eye  between  the  edge  of  the  speck  and 
the  pupillary  edge  of  the  iris.  In  many  cases,  however,  'of  partial 
opacity  of  the  cornea,  the  speck  is  so  broad,  that  dilatation  of  the 
pupil  to  the  utmost  extent  attainable  by  belladonna,  cannot  restore 
any  useful  degree  of  vision.  In  these  cases,  then,  and  also  v»^hen 
the  necessity  of  continually  renewing  the  application  of  the  bella- 
donna proves  irksome  or  highly  inconvenient  to  the  patient,  we  are 
naturally  led  to  the  expedient  of  removing  a  portion  of  the  iris  from 
behind  the  lucid  part  of  the  cornea,  or  in  other  words,  of  forming 
an  artificial  pupil.     It  would  evidently  be  impossible,  however,  to 

*  Saggio  di  Osservazioni  e  d'Esperienze  suUe  principali   Malattie  degli   Occhi, 
Pavia,  1801. 


551 

do  this  b)'^  incision,  excision,  or  separation,  according  to  the  modes 
ah-eady  described  as  having  been  adopted  by  Cheselden,  Wenzel, 
and  Scarpa,  without  injuring  the  crystaUine  lens,  and  thereby  pro- 
ducing cataract.  This,  of  course,  must  be  avoided,  and  hence  have 
arisen  certain  necessary  changes  in  the  methods  of  forming  an  ar- 
tificial pupil,  according  to  the  condition  of  the  cornea  and  cr3'stalline 
lens.  In  the  cases  operated  on  by  Cheselden,  Wenzel,  and  Scarpa, 
the  whole  cornea  being  transparent,  and  the  lens  no  longer  occupy- 
ing its  natural  place,  an  aperture  for  the  transmission  of  light  was 
the  whole  object  of  their  solicitude,  it  being  of  little  consequence 
where  or  how  the  new  pupil  was  obtained.  It  is  very  different 
when  the  artificial  aperture  must  be  placed  behind  a  particular  por- 
tion of  the  cornea,  and  when  the  lens  being  transparent  must  be 
left  untouched  in  the  operation.  Wenzel's  excision  of  a  central 
portion  of  the  iris,  was  adapted  for  cases  of  closed  pupil,  after  the 
operation  of  extraction ;  but  could  be  of  no  service  when  the  natu- 
ral pupil  was  open,  and  the  entrance  of  light  into  the  eye  impeded 
merely  by  opacity  of  the  centre  of  the  cornea.  For  this  sort  of 
case,  the  excision  of  a  lateral  portion  of  the  iris  is  the  appropriate 
operation,  and  is  generally  effected  simply  by  making  a  small 
opening  through  the  cornea  close  to  its  edge,  and  snipping  off 
the  portion  of  iris,  which  either  protrudes  with  the  gush  of  aque- 
ous humour,  or  is  easily  dragged  out  with  a  small  hook  or  pair  of 
forceps. 

The  operations  for  artificial  pupil,  although  founded  on  the  three 
simple  plans  of  cutting  through  the  iris,  cutting  out  a  piece  of  it, 
or  separating  part  of  its  circumference  from  the  choroid,  have,  like 
the  operations  for  cataract,  undergone  an  endless  variety  of  modifi- 
cations, suggested  partly  by  tlie  diversity  of  the  diseased  states  of 
the  eye  requiring  an  artificial  pupil,  and  partly  originating  in  the 
peculiar  notions  of  different  operators. 


SECTION    II. DISEASED  STATES  OF  THE  EYE    REQUIRING  THE 

FORMATION  OF  AN  ARTIFICIAL    PUPIL. 

The  diseased  states  of  the  eye,  requiring  that  an  artificial  pupil 
should  be  formed  for  the  restoration  of  vision,  are  almost  entirely 
the  effects  either  of  some  of  the  ophthalmiee,  or  of  inflammation 
consequent  to  some  injury  or  operation.  According  to  the  parts 
affected  in  different  cases,  they  may  be  arranged  under  the  seven 
following  classes. 

I.  Partial  opacity  of  the  cornea.  This  class  includes  those 
cases  in  which  there  is  such  a  degree  of  opacity  of  the  central  por- 
tion of  the  cornea  as  to  cover  the  pupil,  while  the  whole,  or  at  least 
a  part  of  the  circumferential  portion  remains  transparent.  The 
pupil  itself  is  open  ;  the  iris  unadherent ;  every  part,  in  fact,  healthy 
but  the  cornea.     Through  the  transparent  portion  of  the  cornea, 


552 

the  light  enters,  but  is  arrested  by  the  iris  ;  let  a  part  of  this 
opaque  membrane  be  removed,  the  light  passing  through  the  new 
pupil  thus  formed,  will  be  transmitted  to  the  retina,  and  vision  re- 
stored. Should  the  opaque  portion  of  the  cornea  be  so  limited  in 
extent,  that  dilating  the  natural  pupil  by  belladonna  suffices  to  re- 
store a  considerable  share  of  useful  vision,  it  would  be  wrong  to 
hazard  an  operation  ;  but  should  the  opacity  be  so  extensive  that 
dilatation  by  belladonna  adds  little  or  nothing  to  the  patient's  per- 
ception of  objects,  we  withdraw  a  part  of  the  iris  from  behind  the 
lucid  portion  of  the  cornea,  by  the  operation  either  of  lateral  exci- 
sion or  of  separation.  If  the  lucid  portion  of  the  cornea  is  small 
in  extent,  (less  perhaps  than  a  line's  breadth,)  it  would  be  unsafe 
to  cut  into  that  portion,  in  order  to  extract  a  part  of  the  iris  for  ex- 
cision ;  for  should  the  wound  inflame,  the  whole  of  the  transparent 
segment  of  the  cornea  might  thus  be  rendered  opaque,  and  all 
chance  of  restoration  of  sight  destroyed.  In  such  a  case,  the  ope- 
ration of  separation  must  be  had  recourse  to,  not,  however,  in  the 
manner  practised  by  Scarpa,  and  shortly  described  in  the  preced- 
ing section,  but  by  meaus  of  a  hook  introduced  through  an  inci- 
sion of  the  cornea,  the  incision  being  made  at  a  distance  from  the 
lucid  segment.  On  the  other  hand,  when  there  is  a  considerable 
field  of  transparent  cornea,  its  edge  is  to  be  opened,  the  iris  allowed 
to  protrude,  or  a  portion  of  it  extracted,  and  as  much  of  it  re- 
moved with  the  scissors  as  shall  form  a  sufficient  artificial  pupil. 

II.  Partial  opacity  of  the  cornea,  with  partial  adhesion  of 
the  iris  to  the  cornea.  The  cases  falling  under  this  head  are 
generally  the  results  of  penetrating  wound  or  ulcer  of  the  cornea. 
Like  the  cases  of  uncombined  opacity  of  cornea,  those  belonging 
to  this  class  vary  remarkably  in  regard  to  the  extent  of  opacity. 
The  central  portion  onl}^  may  be  opaque,  or  the  opacity  ma)'^  leave 
only  a  small  segment  of  lucid  cornea  close  to  the  sclerotica.  The 
iris  also  is  involved,  in  these  cases,  in  very  different  degrees.  The 
edge  of  the  pupil,  in  a  single  point  merely,  may  be  adherent  to 
the  cornea,  without  almost  any  distortion  of  the  pupil.  In  other 
cases,  although  the  edge  of  the  pupil  has  not  been  dh-ectly  involved 
in  the  ulcer  which  has  ended  in  the  opacity  of  the  cornea,  the  pu- 
pil is  distorted,  contracted,  and,  though  partially  open,  is  so  hid 
behind  the  leucoma,  that  vision  is  completely  impeded.  In  a  third 
set  of  cases,  the  whole  circumference  of  the  pupil  has  been  involved 
in  the  ulcer,  and  is  therefore  adherent  to  the  cicatrice,  while  the 
anterior  chamber  is  almost  obhterated  by  the  advancement  of  the 
iris  towards  the  cornea.  In  a  fourth  set,  the  united  portion  of  the 
cornea  and  iris  may  have  protruded,  so  as  to  form  a  partial  staphy- 
loma. 

The  same  rule  will  guide  us  in  the  choice  of  an  operation  for 
artificial  pupil  in  the  cases  of  this  class,  as  in  those  of  the  former ; 
namely,  that  when  there  remains  only  a  small  segment  of  the  cor- 
nea transparent,  this  is  too  valuable  to  be  tampered  with,  no  incision 


553 

must  be  risked  into  that  transparent  segment,  lest  it  should  thereby 
be  rendered  permanently  opaque,  but  an  incision  must  be  made  at 
a  distance,  and  the  iris  withdrawn  from  behind  the  transparent 
part  by  separation  from  the  choroid.  When,  on  the  other  hand, 
there  is  a  considerable  portion  of  the  cornea  transparent,  lateral  ex- 
cision will,  in  general,  be  had  recourse  to ;  not,  indeed,  with  the 
same  facility  as  if  there  was  no  adhesion  between  the  iris  and  cor- 
nea, but  still  without  any  insurmountable  difficulty.  The  iris  v;ill 
probably  not  be  protruded  by  the  mere  pressure  of  the  aqueous  hu- 
mour rushing  through  the  incision  of  the  cornea,  but  the  hook  or 
the  forceps  will  in  general  serve  easily  to  extract  the  portion  of  iris 
which  is  to  be  removed  by  the  scissors. 

III.  Closure  of  the  pupil,  the  lens  and  capsule  being 
tratisparent.  Closure  of  the  pupil  from  inflammation  of  the  iris, 
without  any  opacity  of  the  capsule,  or  any  adhesion  between  it  and 
the  iris,  is  certainly  a  very  rare  occurrence,  and  from  the  appear- 
ances presented,  is  exceedingly  liable  to  be  taken  for  a  case  of 
closure  of  the  pupil  with  adhesion  to  an  opaque  capsule.  As  it  is 
a  rule  from  which  there  is  no  exception,  that,  in  forming  an  arti- 
ficial pupil,  if  the  lens  and  capsule  are  transparent  before  the  ope- 
ration, they  must  be  left  untouched,  it  would  evidently  be  wrong, 
in  any  case  in  which  there  was  reason  to  suppose  that  closure  of 
the  pupil  was  the  wliole  amount  of  disease,  to  have  recourse  to  the 
operation  of  incision,  or  to  perform  any  operation  except  in  the  most 
cautious  manner.  Lateral  excision  is  indicated  in  such  a  case. 
After  laying  hold  of  a  portion  of  the  iris  and  extracting  it  for  ex- 
cision, a  clot  of  unorganized  lymph  may  be  found  to  occupy  the 
posterior  chamber,  without  adhering  to  the  capsule  ;  and  is  to  be 
removed.  Perhaps  we  discover,  on  removing  a  portion  of  the  iris, 
that  our  great  caution  has  been  unnecessary,  as  the  capsule  is 
opaque  ;  or  on  attempting  to  extract  a  portion  of  the  iris  for  exci- 
sion, we  find  so  firm  an  adhesion  between  that  membrane  and  the 
capsule,  that  it  is  impossible  to  effect  our  object,  so  that  some  other 
mode  of  procedure  must  be  adopted.  No  evil,  however,  can  arise 
from  our  having  entertained  a  more  favourable  view  of  the  case 
than  we  find  to  be  warranted  by  the  state  of  the  parts,  when  we 
come  to  operate.  Through  the  artificial  pupil  formed  by  lateral 
excision,  we  may  immediately  introduce  the  needle  and  divide  the 
cataract,  extracting  the  lens  in  fragments,  and  perhaps  the  capsule 
also ;  or  we  may  delay  till  the  eye  has  recovered  from  what  has 
been  done,  and  afterwards  proceed  to  remove  the  cataract  from  be- 
hind the  new  pupil. 

IV.  Closure  of  the  pupil,  vnth  adhesion  of  the  iris  to  the 
crystalline  capsule.  In  this  case,  something  requires  to  be  done 
for  the  removal  of  the  lens,  either  at  the  moment  of  forming  the 
artificial  pupil,  or  subsequently.  For  the  formation  of  the  arti- 
ficial pupil,  incision  is  sometimes  chosen,  and  performed  through 
an  opening  of  the  cornea  sufficiently  extensive  to  allow  the  lens 

70 


554 

to  be  extracted.  Cheselden's  method  has  also  been  practised  ia 
such  cases,  the  lens  being  divided  by  the  iris-knife,  and  its  frag- 
ments thrust  forwards  through  the  new  pupil  into  the  anterior 
chamber  for  solution.  Some  have  preferred,  in  such  circumstances, 
forming  first  an  artificial  pupil  by  lateral  excision,  and  afterwards 
have  divided  the  lens.  Others  have  chosen  central  excision,  and 
immediately  proceeded  to  extract  the  cataract  through  the  artificial 
pupil. 

y.  Closure  of  the -pupil  after  an  operation  for  cataract.  As 
it  was  in  cases  of  this  kind,  that  Cheselden,  with  such  signal  suc- 
cess, had  recourse  to  a  simple  incision  of  the  iris  for  the  purpose  of 
forming  an  artificial  pupil,  it  may  appear  strange  that  Wenzel  was 
so  disappointed,  when  he  tried  the  same  operation,  that  he  laid  it 
aside,  and  adopted  that  of  central  excision.  The  cases,  however, 
in  which  Cheselden  succeeded,  and  those  in  which  Wenzel  failed, 
in  forming  a  permanent  artificial  pupil  by  incision,  differed,  we 
have  no  doubt,  in  a  most  material  circumstance,  namely,  the  healthy 
or  unhealthy  state  of  the  iris  ;  for,  as  I  shall  have  occasion  in  a 
following  section  to  explain  more  particularly,  an  incision  through 
an  iris,  the  texture  of  wiiich  has  suffered  but  little  from  inflamma- 
tion, is  likely  to  remain  permanently  open,  while  one  through  the 
same  membrane  after  it  has  become  thickened  and  otherwise 
changed  in  texture,  almost  invariably  closes,  and  its  edges  reunite. 
Hence,  it  is  necessary  to  lay  it  down  as  a  rule  regarding  the  cases 
falling  under  this  class,  that  if  the  appearance  of  the  iris  and  the 
history  of  the  case  lead  to  the  conclusion,  that  the  closure  of  the 
pupil  has  taken  place  without  any  severe  or  long  continued  in- 
flammation of  the  iris,  simple  incision  may  be  practised,  either  in 
Cheselden's  method,  or  in  some  of  the  methods  more  recently  da- 
vised  ;  but  that  if  the  iris  appears  to  be  much  altered  in  texture,*'i 
or  if  the  history  of  the  case  declares  that  severe  and  long  continued 
iritis  has  attended  the  closure  of  the  pupil,  excision  or  separation 
ought  to  be  adopted. 

VI.  Closure  of  the  piipil  from  prot}^ii,sion  of  the  iris  after 
extraction.  This  is  a  very  peculiar  case,  inasmuch  as  the  fibres 
of  that  part  of  the  iris  which  is  unconnected  with  the  cornea  are 
completely  on  the  stretch,  so  that  they  are  easily  divided,  and  the 
artificial  pupil  formed  by  incision  instantly  expands.  From  these 
circumstances,  this  case  is  by  far  the  best  suited  for  the  operation 
of  incision.  In  some  of  the  other  cases,  there,  is  room  for  dehb- 
eration  between  the  different  kinds  of  operation,  but  in  this  there 
ajjpears  to  be  none. 

VII.  Partial  opacity  of  the  cornea.,  closure  of  the  pupil,  ad- 
hesion of  the  iris  to  the  cornea  or  to  the  capsule,  and  opacity 
of  the  capsule.  So  complicated  a  case  as  this  might  appear,  on 
first  enunciation,  as  altogether  beyond  relief.  Yet  some  of  the  veiy 
best  recoveries  of  siglit  by  means  of  an  artificial  pupil  have  taken 
place  under  circumstances  of  this  unfavourable  nature.     There  is, 


555 

we  shall  say,  a  lucid  segment  of  cornea,  from  behind  which,  by 
means  of  lateral  excision  or  separation,  we  remove  a  portion  of  the 
iris,  this  reveals  an  opaque  leas  and  capr-ule,  which  after  sometime 
we  remove  by  the  needle,  and  thus  restore  vision. 


SECTION  III. — GENERAL  RULES  REGARDING  ARTIFICIAL  PUPIL* 

1.  As  in  every  instance,  those  states  of  the  eye  which  require 
the  formation  of  an  artificial  pupil,  originate  partly,  if  not  entirely, 
in  inflammation,  the  renewal  of  which  might  prove  fatal  to  the 
success  of  the  operation,  it  is  to  be  received  as  a  general  rule,  that 
no  artificial  pupil  must  be  formed,  unless  the  patient's  general  health 
is  good,  and  the  eye  has  for  a  considerable  space  of  time  been  per- 
fectly free  from  every  symptom  of  inflammation,  except  those  irre- 
movable ones,  to  counteract  the  effects  of  which  the  operation  is 
attempted. 

2.  An  artificial  pupil  ought  never  to  be  formed  in  the  one  eye 
so  long  as  the  individual  is  able  to  see  with  the  other ;  for  to  see 
well  with  the  sound  eye,  he  would  require  to  shut  the  eye  in  which 
the  artificial  pupil  had  been  formed,  and  vice  versa,  the  axes  of 
vision  in  the  two  eyes  seldom,  if  ever,  in  such  circumstances,  being 
correspondent. 

3.  Though  it  must  be  a  mere  experiment,  yet  it  may  sometimes 
occur  that  the  formation  of  an  artificial  pupil  shall  restore  the 
power  of  vision  to  an  eye  which  was  previously  unable  to  distin- 
guish even  between  light  and  shadow.  Generally,  indeed,  it  is 
regarded  as  an  indispensable  condition  for  the  performance  of  this 
operation,  that  the  eye  is  able  to  discriminate  between  the  different 
gradations  df  light ;  yet  it  is  possible,  from  the  natural  pupil  being 
completely  obliterated,  the  iris  at  the  same  time  thickened,  and 
lymph  accunmlated  in  the  posterior  chamber,  added  perhaps  lo 
opacity  of  the  lens  and  capsule,  that  the  patient  shall  be  unable  to 
distinguish  light  from  darkness,  although  the  more  internal  parts 
of  the  eye  are  still  susceptible  of  resimiing  their  office,  were  the 
impediments  now  enumerated  removed  by  operation.  Ponitz,  the 
German  translator  of  Assalini  on  Artificial  Pupil,  mentions  two 
cases,  in  which  he  operated  with  success,  although  the  patients 
were  previously  unable  to  distinguish  even  the  brightest  hght. 

4.  An  operation  for  artificial  pupil  ought  not  to  be  undertaken 
if  there  be  any  formidable  general  disease  of  the  eye  present,  such 
as  inflammation,  varicose  dilatation  of  the  blood-vessels,  bogginess, 
preternatural  hardness,  dropsy,  atrophy,  strabismus,  or  the  like. 

5.  If  the  artificial  pupil  cannot  be  formed  in  or  near  the  centre 
of  the  iris,  and  if  the  operator  has  a  choice  of  placing  it  behind 
either  the  nasal  or  the  temporal  edge  of  the  cornea,  he  ought  to 
prefer  the  former  of  these  two  situations,  both  as  aflTording  a  more 
useful  degree  of  vision,  and  as  causing  less  deformity.     Often, 


556 

however,  the  operator  has  no  choice,  but  must  form  the  artificial 
pupil  behind  the  only  portion  of  cornea  which  remains  lucid, 
whether  that  be  at  the  temporal  or  nasal  edge,  at  the  upper  or  the 
lower.  It  is  easier,  in  general,  to  form  an  artificial  pupil  at  the 
temporal  edge  than  at  the  nasal ;  and  it  is  urged  by  Mr.  Gibson, 
that  the  patient  enjoys  a  greater  field  of  vision  when  the  pupil  is 
towards  the  temple.  This,  however,  may  be  doubted  ;  and,  at 
any  rate,  there  is  a  much  greater  degree  of  awkwardness  in  the 
appearance  and  employment  of  an  eye  in  which  the  pupil  is  behind 
the  temporal  edge  of  the  cornea,  the  patient  evidently  finding  it 
difiicult  to  turn  the  eye  so  as  to  bring  the  pupil  into  the  necessary 
direction,  and  embrace  with  it  the  usual  range  of  objects. 

6.  If  an  artificial  pupil  is  to  be  formed  in  each  eye,  some  direct 
us  to  make  the  one  at  the  temporal,  and  the  other  at  the  nasal 
edge,  alleging  that  in  this  way  there  is  a  greater  degree  of  corres- 
pondence between  them,  than  if  they  were  formed  in  any  other 
situations  except  in  the  centre  of  the  eyes.  If  both  pupils  are 
towards  the  temple,  as  in  Professor  Maunoir's  patient,  the  Marquis 
de  Beaumanoir,*  the  appearance  is  far  from  being  natural  or 
agreeable. 

7.  In  all  cases  in  which  the  lens  and  capsule  are  transparent,  the 
artificial  pupil  must  be  formed  in  such  a  way  as  to  leave  these  parts 
untouched. 

8.  As  an  artificial  pupil  generally  possesses  no  power  of  con- 
tracting or  dilating,  care  must  be  taken  that  it  is  made  neither  too 
large  nor  too  small.  It  is  remarkable  indeed,  how  useful  a  very 
small  artificial  pupil  may  prove,  as  is  Avell  illustrated  in  the  celebrat- 
ed instance  of  Mr.  Sauvages,  operated  on  by  Deraours.t  In  gen- 
eral, however,  so  small  a  pupil  does  not  prove  very  serviceable ; 
while,  on  the  other  hand,  an  artificial  pupil  much  above  the  medi- 
um size  of  the  natural  one,  exposes  the  eye  to  be  constantly  dazzled, 
and  is  thus  rendered  comparatively  useless. 

9.  The  formation  of  an  artificial  pupil  ought  rarely,  if  ever,  to 
be  attempted  in  a  strumous  subject  under  the  age  of  puberty,  more 
especially  if  the  diseased  state  of  the  eye  rendering  this  operation 
necessary  has  originated  in  strumous  ophthalmia,  independent  of 
injury.  After  an  operation  in  such  a^subject,  inflammation  of  the 
strumous  character  is  almost  sure  ta  follow,  and  will  probably  de- 
stroy the  eye.  In  the  course  of  a  few  years  after  puberty,  the  ope- 
ration may  be  performed  with  less  danger. 

*  Medico  Chirargical  Treinsactions,  Vol.  vii.  pp.  305,  309.     London,  1816. 
t  Traite  des  Maladies  des  Yeux,  Tome  iii.  p.  426.     Planche  46,  Fig.  1.     Paris, 
1818.     London  Medical  and  Physical -Journal  for  JhIj  1826,  p.  42,  Plate  1.  Fig.  2. 


557 


SECTION  IV. INCISION,  EXCISION,  AND  SEPARATION  COMPARED. 

CONDITIONS  NECESSARY  FOR  THESE  OPERATIONS. 

I.  The  simplest  mode  of  forming'  an  artificial  pupil  consists  in 
nothing  more  than  one  or  more  incisions  through  the  substance  of 
the  iris,  made  in  expectation  that  the  opening  so  formed  will  gape, 
and  continue  permanent.  If  the  opening  through  the  iris  is  formed 
by  one  incision,  it  may  run  horizontally,  so  as  to  form  a  pupil  le- 
sembhng  that  of  the  ruminating  animals,  or  perpendicularly,  so  as 
to  form  one  resembling  the  pupil  of  the  cat-tribe.  The  artificial 
pupil  may  be  oblique  in  its  direction,  may  occupy  the  superior,  infe- 
rior, nasal,  or  temporal  portion  of  the  expanded  iris  ;  it  may  be 
formed  not  in  a  straight,  but  (as  Janin  preferred)  in  a  curved  line ; 
or  it  may  be  formed,  (as  Maunoir  has  recommended,)  by  two  inci- 
sions meeting  each  other  at  an  acute  angle.  The  formation  of  an 
artificial  pupil  by  incision  may  be  accomplished  by  passing  the  nee- 
dle or  knife  through  the  cornea,  and  thus  commencing  upon  the 
anterior  surface  of  the  iris ;  or  the  instrument  may  be  entered 
through  the  sclerotica,  and  then  passed  through  the  iris  into  the 
anterior  chamber.  These  particulars  will  be  determined,  partly  by 
the  views  of  the  operator,  and  partly  by  the  state  of  the  eye  upon 
which  he  is  to  operate. 

It  must  be  evident,  that  it  is  an  indispensable  condition  for  the 
success  of  incision,  that  the  iris  shall  be  in  such  a  state  as  shall  se- 
cure the  dilatation  of  the  new  pupil,  as  soon  as  the  operation  is 
completed.  If  the  artificial  pupil  do  not  dilate,  the  iris  will  heal  in 
a  few  hours,  and  the  patient  will  be  just  where  he  was.  In  order 
that  the  new  pupil  shall  dilate,  it  is  necessary  that  the  substance  of 
the  iris  be  in  a  tolerably  healthy  state.  If  that  membrane  has  sus- 
tained violent,  long  continued,  or  frequently  repeated  inflammation, 
its  fibres  are  rendered  incapable  of  conti'acting,  and  consequently 
if  such  attacks  have  ended  in  closure  of  the  natural  pupil,  the  iris 
is  unfit  to  be  operated  on  by  incision.  Whenever,  then,  the  history 
of  the  case  and  the  appearances  of  the  eye  lead  us  to  believe  that 
there  has  been  severe  iritis,  we  ought  to  choose  some  other  method 
of  operating.  It  is  not,  however,  in  every  case  of  closure  of  the 
natural  pupil  from  iritis,  that  the  fibres  of  the  iris  are  rendered  in- 
capable of  contracting,  but  only  when  the  inflammation  of  the  iris 
has  been  severe  and  long  continued,  ending  in  thickening  of  that 
membrane,  with  sanguineous  or  lymphatic  deposition  in  its  sub- 
stance, or  on  its  porterior  surface. 

It  is  interesting  to  inquire  how  those  differences  of  opinion  have 
arisen,  which  have  existed  in  the  minds  of  operators  regarding  in- 
cision, and  how  this  operation  has  occasionally  succeeded,  and  at 
other  times  completely  failed.  The  explanation  will  be  found  in 
the  difference  of  cases,  and  in  the  fitness  of  some,  and  unfitness  of 
others,  for  this  operation.  In  proof  of  this,  we  may  refer  to  the  tes- 
timony of  Janin.     The  first  case  in  which  he  performed  incision 


55S 

was  one  of  obliteralion  of  the  pupil  from  inflammation  after  ex- 
traction ;  and  the  second,  obhteration  from  severe  oplithahnia.  la 
both,  he  made  a  horizontal  iocision  to  the  extent  of  two-thirds  of 
the  diameter  of  the  iris,  and  in  both,  on  opening  the  eyes  some 
days  after  the  operations,  he  found  the  artificial  pupils  completely 
closed,  and  the  incisions  healed.* 

I  beheve  that  we  are  warranted  in  asserting,  that  the  closure  of 
these  two  artificial  pupils  would  not  have  taken  place,  had  the  sub- 
stance of  the  iris  been  in  a  natural  state  ;  and  the  proof  of  this  may 
be  brought  from  the  testimot^y  of  Janin  himself.  In  several  in- 
stances, while  performing  extraction  of  the  cataract,  this  operator 
happened  accidentally  to  wound  the  iris.  Reasoning  from  his  ex- 
perience in  the  two  cases  of  artificial  pupil,  he  expected  that  these 
accidental  u'ounds  would  heal.  Here,  too,  however,  he  was  disap- 
pointed. These  incisions  had  been  made  in  healthy  irides,  and  on 
opening  the  eyes  some  days  afterwards,  he  found  them  more  di- 
lated than  at  the  moment  of  operation.!  Had  he  been  led  from 
these  striking  facts,  to  compare  his  failures  in  the  operation  of  inci- 
sion with  the  success  which  had  attended  this  method  of  operating 
in  the  hands  of  Cheselden,  he  might  have  been  led  to  the  true 
cause  of  the  diversity  of  results  :  namely,  the  different  states  in 
which  the  substance  of  the  iris  mast  have  been  at  the  moment  of 
operation.  Instead  of  this,  Janin  was  led  to  attribute  his  want  of 
success  to  something  faulty  in  the  form  and  direction  of  his  incision. 
The  true  cause  unfortunately  escaped  him,  as  it  did  many  of  his 
successors,  who,  omitting  a  careful  examination  of  the  whole  facts, 
bestowed  their  attention  chiefly  on  the  most  eflfectual  mode  of  di- 
viding the  two  sets  of  supposed  muscular  fibres  of  the  iris.  It  was 
not  in  fact  till  the  publication  of  Sir  William  Adams's  cases  of  ar- 
tificial pupil  by  incision,  that  the  objections  thrown  out  against  this 
operation  by  Scarpa  and  others,  were  in  some  measure  removed ; 
although  even  Sir  William  missed  the  true  secret  of  his  own  suc- 
cess, attributing  it  not  to  the  condition  of  the  iris  upon  which  he 
operated,  but  to  the  form  of  his  knife,  and  the  extent  of  his  incision. 
We  need  not  hesitate  to  assert,  that  in  every  case  in  which  the 
substance  of  the  iris  is  not  greatly  altered  by  inflammation,  we  may 
confidently  expect  a  successful  issue  to  the  operation  by  incision, 
let  the  incision  be  in  whatever  direction,  or  in  whatever  part  of  the 
iris  it  may,  above,  or  below,  or  in  the  hne  of  the  natural  pupil,  and 
whether  it  is  a  mere  pin-hole  or  extends  to  two-thirds  of  the  diam- 
eter of  the  iris. 

Besides  a  tolerably  healthy  state  of  the  iris,  there  are  other  con- 
ditions necessary  for  incision.  Among  these  we  may  mention  a 
considerable  field  of  transparent  cornea,  opposite  to  that  portion  of 
iris  Vifhich  is  to  be  divided.     We  would   never  think  of  incision,  if 


*  Memoires  et  Observations sur  I'CEil,  pp.  182,  184.     Lyon,  1772. 
t  Ibid.  pp.  185,  186,  187. 


i 


559 

there  were  merely  a  narrow  segment  of  cornea  transparent,  and 
all  the  rest  opaque ;  for  in  such  a  case  an  artificial  pupil  by  in- 
cision could  be  little  more  than  a  mere  fissure,  whereas  a  more 
considerable  and  more  useful  pupil  might  be  formed  by  separating 
the  iris  from  the  choroid,  and  removing  it  completely  from  behind 
the  lucid  portion  of  the  cornea. 

Another  condition  necessary  for  incision,  is  that  the  iris  shall 
possess  a  certain  degree  of  tension,  and  be  actually  fixed  in  some 
measure,  either  by  closure  of  the  natural  pupil,  or  by  partial  ad- 
hesion to  the  cornea.  This  condition  exists  in  a  very  striking 
manner  in  those  cases  of  closure  of  the  pupil  and  dragging  of  the 
iris  which  occur  from  prolapsus  of  this  membrane  after  extraction 
of  the  cataract.  Not  merely  is  the  iris  easily  divided  in  these  cases, 
but  the  new  pupil  instantly  gapes  and  rarely  afterwards  contracts, 
so  that  they  are  actually  the  best  cases  for  the  operation  of  inci- 
sion. If,  on  the  other  hand,  the  pupil  is  perfectly  free,  the  iris 
will  glide  from  before  the  point  of  any  instrument  with  which  we 
might  attempt  to  divide  it,  and  even  if  transfixed  it  would  be 
difficult  to  give  the  incision  the  form  and  extent  required.  In  all 
cases,  then,  in  which  partial  opacity  of  the  cornea  merely  is  the 
occasion  of  our  having  recourse  to  the  formation  of  an  artificial 
pupil,  incision,  on  account  of  the  danger  of  wounding  the  crys- 
talline capsule,  as  well  as  for  the  reason  now  stated,  would  be 
improper. 

II.  As  excision  is  the  cutting  out  and  completely  removing  from 
the  eye  a  portion  of  the  iris,  this  operation  can  be  performed  con- 
veniently and  safely  only  through  the  cornea.  It  will  require  also 
a  considerable  opening  in  the  cornea,  in  order  to  allow  either  a 
spontaneous  protrusion  of  the  portion  of  iris  which  is  to  be  removed, 
or  the  introduction  of  such  instruments  as  are  intended  to  drag  forth 
the  portion  to  be  cut  off,  or  to  be  employed  within  the  eye  in  snipping 
it  out.  As  to  the  situation,  form,  and  dimensions  of  an  artificial 
pupil  by  excision,  these  must  depend  partly  on  the  fancy  of  the 
operator,  but  chiefly  on  the  uncontrollable  circumstances  in  which 
the  iris,  cornea,  and  other  parts  implicated  in  the  operation  are 
placed.  Above  all,  the  situation  and  dimensions  of  the  new  pupil 
must  depend  on  the  extent  and  place  of  the  transparent  part  of  the 
cornea. 

The  cases  in  which  the  pupil  is  open  and  the  iris  free,  and 
which  we  have  already  mentioned  to  be  totally  unfit  for  incision, 
are  the  very  best  for  excision,  for  it  is  evident  that  it  is  only  in  such 
cases  that  the  protrusion  of  the  iris  through  the  wound  of  the  cor- 
nea, will  take  place  with  that  degree  of  facility,  and  to  that  extent, 
which  vv'ill  enable  us  to  finish  the  operation  simply  by  laying  hold 
of  the  prolapsed  poilion  of  iris  with  the  forceps,  and  snipping  it  off 
with  the  scissors.  If,  on  the  other  hand,  the  natural  pupil  is  com- 
pletely closed,  and  the  posterior  surface  of  the  iris  glued  to  the 
parts  behind  it,  excision  in  this  easy  method  is  impracticable,  as  a 


560 

protrusion  of  the  iris  through  the  wound  of  the  cornea  will  neither 
take  place  spontaneously,  nor  can  it  be  readily  effected  by  means  of 
the  hook  or  forceps  introduced  into  the  anterior  chamber. 

In  those  cases  in  which  the  iris  is  only  in  a  small  extent  adhe- 
rent to  the  cornea,  excision  may  in  general  be  performed  with  ease, 
a  very  limited  adhesion  seldom  preventing  a  spontaneous  protru- 
sion of  the  iris  through  the  wound  of  the  cornea.*  But  if  the  ad- 
hesion between  the  iris  and  the  cornea  is  extensive,  involving  per- 
haps the  whole  circumference  of  the  pupil,  it  would  be  difficult,  and 
perhaps  impossible,  to  effect  a  protrusion,  even  with  the  aid  of  the 
hook  or  forceps. 

III.  Separation  is  an  operation  which  by  some  has  been  deemed 
applicable  in  almost  every  case  requiring  the  formation  of  an  arti- 
ficial pupil,  but  which  I  am  incHned  to  employ  much  less  frequently 
than  either  incision  or  excision.  It  is  undeniable  that  there  is  no 
case  in  which  separation  might  not  be  performed,  let  it  be  one  of 
partial  opacity  of  the  cornea  merely,  of  closure  of  the  natural  pupil, 
or  of  some  of  the  complicated  consequences  of  injury  or  of  inflam- 
mation ;  but  it  is  also  true  that  separation,  on  account  of  the  lace- 
ration of  blood-vessels  and  nerves  with  which  it  is  attended,  is  more 
severe  and  painful,  accompanied  by  greater  danger  to  the  eye, 
and  followed  by  a  more  tedious  recovery.  The  artificial  pupil 
formed  by  separation,  unless  very  particular  precautions  are  adopted, 
is  also  extremely  apt  to  close,  the  portion  of  iris  which  has  been 
separated  returning  to  its  former  situation,  and  re-adhering  to  the 
choroid.  For  these  reasons,  we  should  always  seek  to  attain  our 
object  by  excision  or  incision,  and  only  if  these  are  unlikely  to  fulfil 
our  intention^  ought  we  to  have  recourse  to  separation. 

There  is  one  advantage  which  separation  possesses  over  incision, 
and  which  may  therefore  serve  in  certain  cases  to  recommend  it ; 
namely,  that  with  proper  care  the  lens  and  capsule  may  be  left 
untouched  in  the  former  operation,  which  can  very  seldom  be  done 
in  the  latter.  By  separation  also  we  are  able  to  form  the  largest 
possible  pupil  admitted  by  the  state  of  the  parts,  an  advantage, 
when  the  lucid  segment  of  cornea  is  small,  of  no  mean  importance. 

*  Vi^on  may  occasionally  be  restored  in  cases  of  this  sort,  simply  by  separating  the 
portion  of  adherent  iris  from  the  cornea,  or,  if  this  cannot  be  accomplished,  by  cutting 
across  the  adherent  part,  thus  freeing  the  iris,  and  allowing  the  natural  pupil  (in  the 
latter  instance  a  little  enlarged)  to  resume  its  functions.  A  quarter-section  being 
made  at  the  edge  of  the  cornea,  a  small  probe  may  be  introduced,  and  an  attempt 
made  to  separate  the  adhesion,  which  may  sometimes  succeed,  if  the  adhesion  has  been 
consequent  merely  to  inflammation,  without  any  ulceration  of  the  cornea,  or  prolapsus 
of  the  iris.  If  it  does  not  succeed,  we  may  either,  with  Beer,  introduce  Cheselden's 
iris-scalpel,  and  cut  the  adherent  point  of  iris  across,  or,  as  Assalini  recommends,  use 
a  very  small  pair  of  scissors  for  the  same  purpose.  Should  this  abscission  of  the  iris, 
as  it  may  be  called,  seem  insufficient  to  restore  the  natural  pupil  to  its  office,  the 
opaque  part  of  the  cornea  still  covering  it  too  much  to  permit  die  necessary  quantity 
of  light  to  enter  the  eye,  we  may  immediately  enlarge  the  pupil  by  the  excision  of  a 
portion  of  the  iris.  Cases  of  this  sort  are  capable  of  being  improved,  however,  simply 
by  prolapsing  a  portion  of  the  iris,  without  cutting  it  off;  a  method  of  operating  success- 
fully employed  by  Himly. 


561 

It  has  been  stated  in  a  previous  section,  that  Scarpa  and  Schmidt 
practised  separation  simply  by  introducing  a  curved  needle  through 
the  sclerotica,  and  with  its  point  dragging  away  the  nasal  edge  of 
the  iris  from  the  choroid.  This  might  no  doubt  be  done  with  im- 
punity in  cases  of  closure  of  the  natural  pupil  after  an  operation 
for  cataract,  but  would  be  quite  inapplicable  if  the  lens  and  cap- 
sule were  sound.  Hence  another  method  of  performing  separation 
has  been  adopted,  namely,  opening  the  cornea  and  introducing  a 
hook  through  the  anterior  chamber,  avoiding  thus  the  lens  and 
capsule.  Separated,  however,  even  by  the  hook  introduced  in  this 
manner,  the  iris  would  speedily  return  to  its  former  place,  and  the 
new  pupil  be  thus  obliterated,  were  not  some  means  adopted  for 
preventing  this.  To  Langeubeck  we  owe  the  additional  step  of 
bringing  out  through  the  wound  of  the  cornea  a  portion  of  the  sep- 
arated iiis,  allowing  it  to  remain  strangulated  between  the  lips  of 
the  wound  till  adhesion  takes  place,  and  thus  rendering  it  impossi- 
ble for  the  new  pupil  to  close. 

The  situation  and  dimensions  of  an  artificial  pupil  formed  by 
separation,  whether  it  is  to  be  behind  the  nasal  or  the  temporal, 
the  superior  or  the  inferior  edge  of  the  cornea,  and  whether  it  is  to 
be  merely  a  small  chink,  or  a  triangular  opening,  each  side  mea- 
suring a  couple  of  lines,  will  be  determined  by  the  state  of  the  eye 
in  which  the  operation  is  to  be  performed.  In  the  most  favourable 
cases,  an  artificial  pupil  by  separation  assumes  the  figure  of  a  tri- 
angle, its  base  being  circular  and  formed  by  the  cihary  processes, 
and  the  two  other  sides  straight  lines.  But  in  many  instances  we 
employ  this  method  of  operating  when  merely  a  small  segment 
of  the  cornea  remains  transparent,  and  the  iris  every  where  else  is 
imited  to  the  opaque  portion  of  the  cornea,  so  that  the  pupil  must 
necessarily  be  small,  and  it  may  be  impossible  to  produce  the  pro- 
lapsus above  recommended  for  the  purpose  of  preventing  the  iris 
from  retreating  towards  the  choroid. 


SECTION  V. INCISION.* 

It  will  be  found  advantageous,  in  all  the  operations  for  artificial 
pupil,  to  lay  the  patient  along  on  his  back,  with  his  head  raised  on 
a  pillow ;  and  the  assistant  should  be  aware  that  in  these  opera- 
tions he  will  require  to  support  one  or  other  of  the  eyelids  or  both, 
according  as  he  is  directed  by  the  operator.  In  excision,  particu- 
larly, both  hands  of  the  operator  are,  at  a  certain  stage  of  the  opera- 
tion, occupied  with  the  instruments,  and  cannot  therefore  be  spared 
for  holding  open  the  eyelids. 

Although  belladonna  has  in  general  little  or  no  power  over  an 
iris  which  has  suffered  such  a  degree  of  inflammation  as  to  end  in 
closure  of  the  pupil,  there  can  be  no  harm  in  applying  it  on  the 
evening  previous  to  the  operation. 

*   Corotomia  of  the  Germans  ;  from  kopj),  pupil,  and  Ti/xvce,  to  cut. 

71 


562 


I.  Incision  through  the  Sclerotica. 

The  instrument  for  dividing  the  iris  through  the  sclerotica,  is  a 
small  knife,  about  two-thirds  of  an  inch  in  length,  less  than  the 
tenth  of  an  inch  in  breadth,  with  a  straight  back,  sharp  point,  and 
curved  edge,  cutting  for  the  length  of  about  three-tenths  of  an 
inch.  Being  single-edged,  this  instrument  can  be  made  to  cut 
much  keener  than  any  sort  of  cataract  needle,  and  yet  from  its  small 
size  it  passes  through  the  coats  of  the  eye  and  iris  with  facility. 

The  operation  dividesitself  into  three  yjeriods  :  namely,  1st,  The 
introduction  of  the  iris-scalpel  through  tiie  sclerotica  and  choroid, 
and  a  little  way  into  the  vitreous  humour  ;  2diy,  The  passage  of 
the  instrument  through  the  iris  into  the  anterior  chamber  ;  and 
3dly,  The  division  of  the  iris. 

1st  Period.  Directing  the  cutting  edge  of  the  instrument  back- 
wards, the  operator  passes  it  through  the  sclerotica  and  choroid,  at 
the  distance  of  the  eighth  of  an  inch  behind  the  temporal  edge  of 
the  cornea,  and  a  line's  breadth  above  or  below  the  equator  of  the 
eye,  to  the  depth  of  the  eighth  of  an  inch  into  the  vitreous  humour. 

2d  Period.  He  now  carries  the  handle  of  the  instrument  back 
towards  the  temple,  and  at  the  same  time  advances  its  point 
towards  the  union  of  the  temporal  with  the  two  nasal  thirds  of  the 
iris  ;  pressing  forward  its  point,  he  sees  it  appear  from  between  the 
fibres  of  the  iris,  and  project  into  the  anterior  chamber.  He  now 
brings  the  handle  of  the  instrument  forwards,  which  has  the  effect 
of  directing  its  point  towards  the  nasal  edge  of  the  cornea,  and  he 
pushes  it  cautiously  on  through  the  anterior  chamber,  as  far  as  he 
can  do  so  without  touching  the  cornea. 

3c^  Period.  It  is  now  by  a  double  motion  of  the  instrument, 
namely,  backwards  and  outwards,  that  the  iris  is  to  be  divided 
transversely,  to  the  extent  of  two-thirds  of  its  diameter.  This 
will  not  be  accomphshed  by  merely  pressing  on  the  ixis,  nor  by  one 
rapid  stroke  of  the  edge  of  the  iris-scalpel,  but  by  repeated  strokes, 
as  if  we  were  dividing  fibre  by  fibre,  and  by  a  drawing  motion  of 
the  instrument  as  -well  as  pressure  with  its  edge.  If  our  first  at- 
tempt has  not  divided  the  iris  to  a  sufiicient  extent,  the  point  of  the 
scalpel  is  to  be  again  carried  forward,  and  again  withdrawn  until 
the  incision  is  of  the  proper  length.  Before  finally  removing  the 
instrument,  we  ought  to  notice  whether  the  artificial  pupil  expands, 
and  if  the  edges  of  the  incision  do  not  immediately  separate  from 
each  other,  in  consequence  of  the  contraction  of  the  fibres  of  the 
iris,  we  should  open  up  the  pupil  a  little  by  touching  its  edges  with 
the  flat  sides  of  the  instrument.  The  iris-scalpel  is  then  to  be 
withdrawn  in  the  same  line  of  direction  as  that  in  which  it  was 
introduced. 

It  is  evident  that  by  following  these  rules,  an  artificial  pupil  will 
be  formed,  the  direction  of  which  will  not  be  strictly  horizontal, 
but  which  will  run  a  little  obliquely  downwards  or  upwards,  ac- 


563 

cording  as  the  scalpel  has  been  entered  above  or  below  the  equator 
of  the  eye. 

This  method  of  operating  was  adopted  by  Cheselden,  in  cases  of 
closure  of  the  natural  pupil  after  an  operation  for  cataract,  but  it 
has  also  been  occasionally  had  recourse  to,  especially  by  Sir  Wil- 
ham  Adams,*  in  cases  in  which  no  attempt  has  ever  been  made 
to  remove  the  opaque  lens  or  capsule  out  of  the  axis  of  vision. 
When  this  kind  of  complication  exists,  the  primary  steps  of  the 
operation  are  such  as  have  been  already  described.  In  dividing 
the  iris,  the  capsule  and  probably  the  lens  also  will  be  cut  across, 
and  before  withdrawing  the  scalpel,  the  operator  must  endeavour 
to  complete  this  division  as  far  as  he  can.  The  aqueous  humour 
will  by  this  means  be  admitted  to  act  upon  the  fragments  of  the 
divided  lens,  but  should  the  absorption  of  these  appear  afterwards 
retarded,  so  that  they  continue  to  form  an  obstacle  to  vision,  the 
operation  of  division,  in  the  course  of  two  or  three  months  after  the 
formation  of  the  artificial  pupil,  may  be  repeated,  as  in  ordinary 
cases  of  cataract. 

If  the  iris  is  adherent  to  a  much  thickened  capsule,  it  will  be 
difficult  to  perform  incision  in  the  manner  above  described,  and 
even  were  the  iris  and  capsule  divided,  it  is  almost  certain  that 
the  new  pupil  would  not  expand,  but  its  edges  speedily  unite.  If 
we  have  proceeded  to  operate  by  incision  through  the  sclerotica,  in 
such  a  case,  it  is  needless  to  attempt  the  separation  of  the  iris  from 
the  capsule.  It  is  better  to  withdraw  the  scalpel,  and  at  a  future 
period  proceed  to  the  formation  of  an  artificial  pupil  by  some  other 
method,  better  adapted  to  the  circumstances  of  the  case. 

II.  Incision  through  the  cornea. 

1.  With  the  knife.  At  one  period  of  his  practice,  and  in  a 
particular  set  of  cases.  Beer  adopted  a  very  simple,  and,  at  the  same 
time,  sufficiently  successful  mode  of  performing  incision  through 
the  cornea.  The  cases  in  question  were  those  in  which,  in  con- 
sequence of  prolapsus  of  the  iris  after  the  operation  of  extraction, 
the  natural  pupil  was  closed,  or  at  any  rate  so  distorted  and  hid 
behind  the  cicatrice  of  the  cornea,  as  to  be  incapable  of  serving  for 
any  degree  of  useful  vision,  while  at  the  same  time  the  upper  half 
of  the  iris  was  dragged  down  toward  the  cicatrice,  and  its  fibres 
put  very  much  on  the  stretch. 

In  such  cases,  Beer  introduced  obliquely  through  the  upper  part 
of  the  cornea,  and  through  the  iris,  a  double-edged  knife,  aljout 
one-fifth  of  an  inch  in  breadth,  and  shaped  exactly  like  a  lancet. 
He  thus  formed  a  transverse  incision,  directly  behind  the  middle  of 
the  lucid  portion  of  the  cornea,  and  which  from  the  tense  state  of 
the  fibres  of  the  iris  instantly  gaped.t     The  same  operation  may 

*  Practical  Observations  on  Ectropium,  &c.  j).  33.     London,  1812. 
t  Assalini,  Ricerche  sulle  Pupille  Artificiali,  p.  18.  Milano,   1811.     Wagner  de 
Coremorpliosi,  p.  20.  Goettingse,  1818. 


564 

be  practised  through  the  lower  part  of  the  cornea,  when  extraction 
at  the  upper  edge  has  been  followed  by  prolapsus  of  the  iris. 

2.  With  the  scissors.  We  owe  this  method  of  operating  to 
Janin  ;  *  but  it  has  been  greatly  improved  by  Professor  Maunoir,  of 
Geneva.!  Although  more  complicated  in  its  manipulations  than 
the  methods  of  Cheselden  and  Beer,  it  ensures  more  effectually  the 
desired  result ;  and  compared  with  the  operation  through  the  scler- 
otica, is  actually  more  easy  of  performance.  To  divide  the  iris 
with  Cheselden's  scalpel,  has  often  been  found  extremely  difficult 
or  even  impossible,  whereas  with  the  scissors,  the  iris,  in  whatever 
state  it  may  be,  whether  thin,  and  unsupported  except  by  aqueous 
humour  in  the  posterior  chamber,  or  thickened,  and  perhaps  ad- 
herent to  the  capsule,  is  divided  with  the  greatest  ease  and  certainty. 
Even  in  cases  where  the  iris  projects  so  as  nearly  to  touch  the  cor- 
nea, Maunoir's  operation  can  be  performed  with  comparative  fa- 
cihty. 

1st  Period.  An  incision  comprehending  fully  a  fourth  of  the 
circumference  of  the  cornea,  is  made  close  to  its  edge,  and  gene- 
rally towards  the  temple.  If  the  case  is  one  in  which  the  lens  has 
previously  been  removed,  this  incision  need  not  exceed  a  fourth  ; 
but  if  we  contemplate  the  removal  of  a  cataract  through  the  artifi- 
cial pupil,  more  than  a  fourth  of  the  circumference  of  the  cornea 
should  be  laid  open.  This  may  be  done  with  the  extraction  knife,; 
but  the  instrument  which  I  prefer  is  a  small  scalpel,  of  the  same 
form  as  the  iris-scalpel,  but  twice  its  size.  This  instrument  is  to  be 
passed  through  the  cornea  at  the  point  intended  to  form  the  upper 
extremity  of  the  incision,  and  directed  across  the  anterior  chamber  ; 
then,  as  it  is  withdrawn,  the  cornea  is  to  be  ripped  open  to  the  re- 
quisite extent. 

2d  Period.  The  scissors,  with  which  the  incision  of  the  iris  is 
to  be  performed,  must  be  made  with  blades  so  thin  and  narrow, 
that  when  closed  they  do  not  exceed  the  thickness  of  a  common 
probe,  the  blades  being  about  three-fourths  of  an  inch  long,  and 
bent  so  as  to  form  an  angle  of  70"  with  the  middle  hne  of  the  han- 
dles. The  superior  blade,  or  that  which  is  to  pass  between  the 
iris  and  the  cornea,  is  probe-pointed  ;  the  inferior,  which  is  to  pen- 
etrate the  iris,  is  sharp-pointed,  and  about  the  twentieth  of  an  inch 
shorter  than  the  other. 

These  scissors  are  to  be  introduced,  flat,  through  the  wound  of 
the  cornea,  till  they  reach  the  part  of  the  iris  where  the  incision 
ought  to  commence.  They  are  then  to  be  turned  one  quarter 
round  on  their  own  axis,  the  handles  brought  a  little  forwards,  the 
blades  slightly  opened,  the  inferior  or  sharp  blade  passed  through 
the  iris,  and  the  instrument  carried  across  the  eye,  with  its  probe- 

*  Memoires  et  Observations  sur  I'CEil,  p.  191.     Lyon,  1772. 

t  Memoires,  sur  I'Organization  de  I'Iris  et  I'Operation  de  la  Pupille  Artificielle. 
Psris,  1812.  Scai-pa,  Trattato  delle  principali  Malattie  degli  Occhi.  Vol.  ii.  p.  118. 
Pa\ia,  1816. 


565 

pointed  blade  before,  and  the  other  behind  the  iris,  as  near  to  the 
nasal  edge  of  the  cornea  as  it  is  meant  to  extend  the  incision. 

3d  Period.  The  scissors  are  now  to  be  sharply  closed,  and  the 
iris  will  be  divided.  Such  is  the  method  of  operating  with  the  scis- 
sors, when  the  fibres  of  the  iris  are  upon  the  stretch,  as  in  cases  of 
prolapsus  after  the  operation  of  extraction  ;  but  in  other  cases,  and 
especially  when  we  suspect  the  substance  of  the  iris  to  be  thickened, 
or  adherent  to  the  capsule,  it  is  proper  to  make  two  incisions,  com- 
mencing at  the  same  point,  and  divaricating  from  one  another  at 
an  acute  angle.  The  triangular  flap  thus  formed  gradually  shrivels 
up  towards  its  base,  leaving  an  artificial  pupil,  generally  of  suffi- 
cient size,  permanent,  preserving  sometimes  a  three-sided,  but  more 
frequently  assuming  a  quadrilateral  figure.  When  closure  of  the 
pupil  is  combined  with  cataract,  the  incisions  above  described  will 
lay  open  the  capsule,  and  may  even  divide  the  lens,  the  fragments 
of  which  the  operator  ought  to  endeavour  by  gentle  pressure  to  bring 
forwards  through  the  artificial  pupil  into  the  anterior  chamber, 
whence  they  are  to  be  extracted  by  means  of  the  scoop  if  they  are 
soft,  or  the  hook  if  hard.  It  may  sometimes  be  possible  to  extract 
even  the  capsule  through  the  artificial  pupil.  If  a  portion  of  the 
capsule  is  firmly  adherent  to  the  triangular  flap  of  the  iris,  it  will 
shrink  along  with  this,  and  form  no  obstacle  to  vision.  Any  frag- 
ments of  the  lens  which  may  be  left  will  gradually  dissolve  in  the 
aqueous  humour. 

It  is  by  no  means  indispensable  that  two  incisions  should  be 
made,  to  permit  the  extraction  of  a  cataract  through  the  artificial 
pupil,  formed  by  the  scissors ;  nor  is  it  necessary  that  the  incision 
of  the  iris,  in  cases  of  closed  pupil  combined  with  cataract,  should 
be  transverse.  Maunoir  has  recorded  a  case,  in  which  he  opened 
the  lower  part  of  the  cornea,  with  the  pointed  blade  of  his  scissors, 
penetrated  the  iris  at  the  distance  of  a  line  from  its  circumference, 
carried  that  blade  behind  the  lens,  closed  the  scissors,  and  thus  cut 
through  the  lens,  its  capsule,  and  the  iris  in  a  vertical  direction. 
The  pupil  immediately  became  larger.  The  two  segments  of  the 
capsule  were  separated,  and  showed  a  broken  lens  of  a  bluish-grey 
colour,  the  capsule  being  yellowish-white.  The  lens  was  easily 
extracted,  piece  by  piece,  with  a  small  scoop.  The  larger  segment 
of  the  capsule  was  then  removed  with  the  forceps.  The  pupil,  in 
the  form  of  a  weaver's  shuttle,  now  appearing  of  a  very  good  size, 
the  other  fragment  of  the  capsule  was  left,  lest  the  taking  of  it  away 
might  have  made  the  pupil  too  large.* 

Incision  with  the  scissors  may  also  be  practised  in  cases  in  which 
the  iris  is  partially  adherent  to  the  cornea,  as  is  often  the  case  in 
consequence  of  prolapsus  through  a  penetrating  ulcer,  the  natural 
pupil  remaining  partially  open,  and  the  lens  and  capsule  transparent. 
Having  supplied  ourselves  with  a  pair  of  scissors  of  the  same  di- 

*  Medico-Chirurgical  Transactions,  Vol.  ix.  p.  387.    London,  1818. 


566 

mensions  as  those  above  described,  but  with  both  blades  probe-pointed 
and  equal  in  length,  we  introduce  them  through  a  small  section 
of  the  cornea,  pass  one  of  the  blades  within  the  contracted  natural 
pupil,  and  conduct  it  behind  the  iris  until  we  see  that  the  other 
blade  has  reached  the  angle  between  the  cornea  and  the  iris.  The 
latter  is  then  to  be  divided  by  two  incisions,  so  as  to  form  a  trian- 
gular flap,  the  apex  of  which  is  in  the  natural  pupil,  and  the  basis 
behind  the  edge  of  the  cornea.  In  this  operation  the  capsule  and 
lens  ought  to  remain  untouched ;  but  it  must  be  confessed,  that 
there  is  more  risk  in  this  way  of  injuring  those  parts  than  in  the  op- 
tion of  lateral  incision,  which  has  therefore  been  generally  preferred 
in  such  cases. 


SECTION  VI. EXCISION. 

There  are  two  varieties  of  excision,  the  lateral  and  the  central. 
The  latter,  which,  as  has  already  been  stated,  was  the  invention  of 
Wenzel,  is  now  very  rarely  practised  ;  the  former,  which  appears  to 
have  been  first  had  recourse  to  by  Beer,  and  afterwards  by  Gibson, 
is  one  of  the  most  common  modes  of  forming  an  artificial  pupil. 

I.   Lateral  Excisioii. 

The  instruments  necessary  for  this  operation  are  a  knife,  a  hook 
or  pair  of  small  forceps,  and  a  pair  of  curved  scissors.  The  cata- 
ract-knife is  the  one  generally  used,  but  I  have  been  led  to  prefer 
a  broad  iris-scalpel,  as  being  a  more  manageable  instrument,  for 
opening  about  a  fourth  of  the  circumference  of  the  cornea,  close  to 
its  edge.  The  hook  or  forceps  are  employed  for  dragging  out  a 
portion  of  the  iris  through  the  wound  of  the  cornea  ;  unless  that 
membrane  protrudes  spontaneously,  when  the  forceps  are  general- 
ly used  for  laying  hold  of  the  protruding  portion,  till  it  is  snipt  off 
with  the  scissors. 

The  operation  divides  itself,  then,  into  three  periods. 

1st  Period.  The  incision  of  the  cornea  never  requires  to  ex- 
ceed one-third  of  its  circumference,  and  in  general  it  will  be  suffi- 
cient to  open  only  a  fourth.  The  nasal  and  lower  edge  of  the 
cornea  is  to  be  preferred,  when  the  state  of  the  parts  permits  the 
operator  to  choose  the  situation  for  the  artificial  pupil.  Introducing 
the  point  of  the  iris-knife  through  the  edge  of  the  cornea,  and  as 
much  across  the  anterior  chamber  as  the  state  of  the  parts  perjnits, 
the  operator,  as  he  withdraws  the  instrument,  enlarges  the  incision 
to  the  requisite  extent.  If  this  is  done  quickly,  so  as  to  allow  the 
aqueous  humour  to  issue  at  once  from  the  eye,  the  removal  of  the 
knife  will  generally  be  followed  by  a  portion  of  the  iris,  projecting 
through  the  w^ound  like  a  small  bag. 

*  Corectomia  of  the  Germans  ;  from  xogx,  pupil,  at,  out,  and  TifAvm,  to  cut. 


567 

2d  Period.  If  no  spontaneous  prolapsus  takes  place,  the  ope- 
rator with  the  point  of  the  scoop  should  open  a  little  the  wound  of 
the  cornea,  at  the  same  time  making  gentle  pressure  with  the  fin- 
ger on  the  opposite  side  of  the  eyeball,  when  the  iris  will  frequent- 
ly appear  between  the  edges  of  the  wound,  and  may  be  laid  hold  of 
with  the  forceps.  What  is  laid  hold  of  is  to  be  cautiously  drawn 
out,  care  being  taken  to  include  the  edge  of  the  natural  pupil  in  the 
portion  thus  prolapsed. 

Still,  should  no  protrusion  of  the  iris  take  place,  or  should  the 
edge  of  the  natural  pupil  adhere  to  the  cornea  in  a  considerable 
part  of  its  extent,  so  that  the  iris  cannot  spontaneously  protrude,  it 
becomes  necessary  to  introduce  either  the  hook  or  the  forceps,  lay 
hold  of  the  iris,  and  cautiously  extract  as  much  as  may  be  sufficient 
for  the  formation  of  an  artificial  pupil  of  medium  size.  In  doing 
this,  care  must  be  taken  to  avoid  touching  the  crystaUine  capsule, 
which,  in  cases  where  we  have  recourse  to  the  operation  of  lateral 
excision  is  generally  transparent.  We  must  also  calculate  with 
care  the  extent  of  iris  which  we  are  to  extract ;  for  if  a  very  small 
portion  only  is  protruded,  the  operation  may  prove  almost  fruitless, 
from  the  minute  size  of  the  artificial  pupil  which  will  be  formed ; 
while,  on  the  other  hand,  if  a  very  large  portion  is  grasped  by  the 
forceps  or  drawn  out  with  the  hook,  the  object  of  the  operation 
may  be  equally  frustrated  by  the  weakness  of  sight  attendant  on 
too  large  a  pupil.  The  latter  error  is  that  into  which  the  operator 
is  more  apt  to  fall.  The  snipping  off  of  a  flaccid  bit  of  iris,  appa- 
rently not  larger  than  an  ordinary  pin-head,  will  sometimes  form 
an  artificial  opening  much  beyond  the  medium  size  of  the  natural 
pupil.  Removing  too  much  of  the  iris  is  also  by  far  the  more  seri- 
ous error  of  the  two,  in  as  much  as  it  scarcely  admits  of  any  reme- 
dy, whereas,  if  the  operator  sees  that  at  the  first  snip,  he  has  re- 
moved too  little,  he  can  either  extract  and  cut  off  an  additional  por- 
tion, or  enlarge  the  pupil  by  incision. 

3d  Period.  The  operator,  holding  with  the  one  hand  the  piece 
of  iris  grasped  between  the  blades  of  the  forceps,  with  the  other 
employs  the  scissors  for  snipping  it  off.  During  this  period  of  the 
operation,  it  is  evident  that  the  lids  must  be  committed  entirely  to 
the  charge  of  the  assistant.  The  operator  also  should  take  care  to 
have  the  scissors  close  at  hand  before  laying  hold  of  the  piece  of 
iris  with  the  forceps,  that  he  may  not  be  obliged  to  search  for  them, 
in  doing  which,  he  might  readily  drag  out  too  much  of  the  iris,  or 
even  separate  it  from  the  choroid.  One  of  Beer's  pupils  invented 
an  instrument  for  this  operation,  in  which  a  hook  and  pair  of  scissors 
were  combined,  but  which  proved  too  complicated  to  be  easily 
managed. 

If  any  portion  of  the  iris  remains  protruding  through  the  wound, 
it  is  to  be  reduced  with  the  point  of  a  probe.  The  operator  is  now 
to  rub  gently  the  front  of  the  eye  through  the  medium  of  the  upper 
eyelid,  and  then  expose  it  to  a  pretty  bright  light,  so  as  to  ascertain 
the  form  and  size  of  the  new  pupil. 


568 

II.  Central  Excision. 

It  is  not  necessary  to  add  any  thing  to  the  account  of  Wenzers 
operation  which  has  been  given  at  page  549.  Both  it,  and  its 
modifications  by  more  modern  operators,  being  objectionable  on  ac- 
count of  the  extensive  incision  of  the  cornea  which  they  require, 
are  but  seldom  attempted.  Mr.  Travers,  however,  tells  us,  that  he 
has  repeatedly,  and  with  perfect  success,  opened  the  cornea  by  a 
semicircular  incision,  raised  the  centre  of  the  iris  wnth  the  forceps 
introduced  under  the  flap  of  the  cornea,  and  clipped  off  as  large  a 
piece  of  the  iris  as  coirld  be  embraced  by  the  convex  scissors.  He 
adds  that  through  such  an  opening,  there  will  be  no  impediment 
to  the  passage  of  the  lens.* 


SECTION  VII. SEPARATION.! 

I.  jSeparatio7i  through  the  Sclei'otica. 

The  operation  for  forming  an  artificial  pupil  by  separation  of 
the  edge  of  the  iris  from  the  choroid,  by  means  of  a  curved  needle 
introduced  through  the  sclerotica,  is  now  almost  entirely  laid  aside. 
Even  when  merely  a  small  segment  of  the  cornea  remains  trans- 
parent, the  iris  adhering  to  the  opaque  part,  and  scarcely  any 
anterior  chamber  existing,  a  case  in  which  it  is  impossible  to  bring" 
out  any  part  of  the  iris  through  an  incision  of  the  cornea,  it  is  not 
unusual  to  pass  the  needle  with  which  the  separation  is  to  be  at- 
tempted, not  through  the  sclerotica,  but  through  the  opaque  part 
of  the  cornea. 

II.  Separation  through  the  Cornea. 
Assalinit  and  Buzzill  appear  to  have  performed  this  operation, 
the  former  as  early  as  17S7,  with  a  very  small  pair  of  forceps,  and 
the  latter  with  a  needle,  in  1788.  In  1801,  Schmidt?  performed 
separation  by  means  of  a  pair  of  forceps  introdnced  through  an 
opening  in  the  cornea,  but  afterwards  adopted  separation  through 
the  sclerotica,  as  not  endangering  the  transparency  of  the  cornea. 
HimlyT  with  a  curved  needle,  and  Bonzel**  with  a  hook,  also 
performed  separation  through  the  cornea.  None  of  these  operators, 
however,  attempted  to  prevent  by  any  means  the  return  of  the 
separated  iris  towards  the  choroid,  an  event  which  is  extiemelj 
apt  to  happen,  if,  as  is  often  the  case  when  an  artificial  pupil  is 
required,  the  substance  of  the  iris  has  previously  suflfered  severely 
from  inflammation. 

*  Synopsis  of  the  Diseases  of  the  Eye,  p.  339.    London,  1820. 
t   CoTodiali/sis  of  the  Germans  ;  from  Kogn,  pupil,  and  Ji:txvce,  to  loosen. 
t  Ricerche  sulle  Pupille  ArtLficiali,  p.  11.     Alilano,  1811.  II  Ibid.  p.  15. 

§  Ophthalmologische  Bibliothek  von  Himly  und  Schmidt.  Vol.  ii.  p.  31.  Jena, 
1803.  f.  > 

"TT  Wagner  de  Coremorphosi,  p.  36.     GoettingsB,  1818. 

**  Journal  der  Practischen  Heilkunde  von  Hufeland  und  Harles,  fUr  Januar, 
1815,  p.  47. 


569 

Langenbeck*  was  the  first  to  whom  it  occurred  to  drag  out 
through  the  cornea  the  portion  of  iris  which  is  separated  from  the 
choroid,  and  by  allowing  the  protruded  piece  to  unite  to  the  hps  of 
the  wound,  to  prevent  in  this  way  the  closure  of  the  new  pupil. 
In  this  operation  he  employed  a  single  hook,  which  is  apt,  instead 
of  separating  the  iris  from  the  choroid,  to  tear  it  through,  or  to  let 
it  go  after  the  separation  is  commenced.  We  are  therefore  highly 
indebted  to  Dr.  Reisingert  for  the  invention  of  an  instrument,  con- 
sisting of  two  delicate  hooks  laid  side  by  side,  which  when  shut 
are  no  bigger  than  a  single  hook.  In  this  state  they  are  introduced 
into  the  anterior  chamber,  but  by  their  elasticity  they  separate  from 
one  another,  and  thus  serve  to  lay  hold  of  the  iris  at  two  different 
points,  and,  being  again  brought  together,  seize  that  membrane 
also  as  a  pair  of  forceps.  Various  other  instruments  have  been 
invented  for  the  same  purpose,  but  none  appear  so  manageable 
and  effective  as  that  of  Reisinger. 

The  operation  divides  itself  into  four  periods ;  viz.  the  incision 
of  the  cornea,  the  introduction  of  the  double  hook  and  laying  hold 
of  the  iris,  the  separation  properly  so  called,  and  the  strangulation 
of  the  separated  piece  of. iris  between  the  Hps  of  the  wound. 

1st  Period.  The  situation  of  the  incision  through  the  cornea 
will  of  course  vary  with  circumstances  ;  but  care  must  always  be 
taken  that  it  shall  be  neither  too  near  nor  too  far  from  that  edge 
of  the  cornea  behind  which  the  artificial  pupil  is  to  be  formed. 
We  shall  suppose  that  this  is  to  be  done  behind  the  nasal  edge  of 
a  cornea,  the  transverse  diameter  of  which  measures  5-lOths  of  an 
inch.  In  this  case,  the  incision  should  be  made  in  a  vertical  direc- 
tion, at  the  distance  of  3-lOths  from  the  nasal  edge,  or  at  any  rate 
not  nearer  to  that  edge  than  the  centre  of  the  cornea.  Were  the 
incision  nearer  than  this  to  the  nasal  edge,  behind  which  we  have 
supposed  that  the  artificial  pupil  is  to  be  formed,  the  separation  of 
the  iris  would  be  too  limited  to  form  a  pupil  of  sufficient  size,  and 
should  an  opaque  cicatrice  result  from  the  incision  of  the  cornea, 
this  would  necessarily  cover  the  new  pupil,  and  frustrate  the  object 
of  the  operation.  On  the  other  hand,  were  the  incision  much 
farther  from  the  nasal  edge,  the  artificial  pupil  would  be  enor- 
mously large,  in  consequence  of  our  continuing  to  detach  the  iris 
till  a  sufficient  portion  of  it  was  drawn  through  the  incision.  But 
by  making  the  incision  at  the  distance  of  3-lOths  of  an  inch  from 
that  edge  of  the  cornea  behind  which  the  separation  is  to  be  effected, 
the  result  will  be  a  triangular  pupil,  of  moderate  size. 

The  incision  will,  in  some  cases,  require  to  be  made  though  a 
lucid  portion  of  the  cornea,  and  in  other  cases  through  one  which  is 
opaque.     This  is  a  matter  of  indifference,  except  only  that  we  see 

*  Wenzel  Uber  den  Zustand  der  Augenheilkunde  in  Frankreich  und  Deutsch- 
land,  p.  107.     NUrnberg,  1815. 

t  Darstellung  einer  ieichten  und  sichern  Methode  kUnstliche  Pupillen  zu  bilden, 
p.  29.     Augsburg,  1816. 

72 


570 

better  how  to  continue  the  operation,  when  the  part  of  the  cornea 
which  is  opened  is  transparent.  It  is  important  that  the  length  of 
the  incision  should  be  fully  2-lOths  of  an  inch  :  for  if  smaller,  it  will 
be  difficult,  or  even  impossible,  to  effect  through  it  the  necessary 
protrusion  of  the  iris,  or  even  to  open  the  double  hook  so  as  effect- 
ually to  lay  hold  of  the  part  to  be  separated.  If,  on  the  other  hand, 
the  incision  is  too  extensive,  the  piece  of  iris  which  is  protruded  will 
not  be  strangulated  with  sufficient  force  by  the  lips  of  the  incision, 
but  will  escape  again  into  the  anterior  chamber,  and  return  towards 
the  choroid. 

A  double-edged  knife  has  been  recommended  for  making  the  in- 
cision, being  pushed  obliquely  through  the  cornea,  and  across  the 
anterior  chamber,  till  its  point  reaches  that  edge  of  the  iris  which  is 
to  be  separated  from  the  choroid.  To  make  the  incision  of  suffi- 
cient length  in  this  way.  the  knife  would  require  to  be  entered  at 
the  distance  of  at  least  3-lOths  of  an  inch  from  that  edge  of  the 
cornea  behind  which  the  artificial  pupil  is  to  be  formed.  Its  edges 
would  also  require  to  divaricate  at  an  angle  of  36".  Pushing  the 
point  of  the  instrument  then  obhquely  through  the  lamellee  of  the 
cornea,  it  is  to  be  carried  through  the  anterior  chamber,  till  it  reaches 
the  angle  between  the  cornea  and  iris,  on  that  side  of  the  eye  where 
the  artificial  pupil  is  to  be  formed,  and  immediately  withdrawn. 
The  incision  will  of  course  be  vertical  in  its  direction,  when  the 
pupil  is  to  be  either  at  the  nasal  or  temporal  edge  of  the  cornea  ; 
horizontal,  if  it  is  to  be  at  the  upper  or  lower  edge  ;  parallel  always 
to  the  basis  of  the  intended  pupil. 

The  incision  must  not  be  perpendicular  to  the  lamellee  of  the  cor- 
nea, but  oblique ;  else  it  will  be  difficult,  if  not  impossible,  to  effect 
the  protrusion  of  the  separated  piece  of  the  iris. 

2d  Period.  It  is  desirable  that  the  sudden  withdrawal  of  the 
knife,  aided  by  the  obliquity  of  the  incision,  should  prevent  the  aque- 
ous humour  from  being  discharged,  till  the  hook  is  introduced. 
Pressing  the  two  branches  of  the  instrument  together,  so  that  it  as- 
sumes the  appearance,  and  does  not  surpass  the  bulk  of  a  single 
hook,  the  operator  slides  it,  flat,  along  the  surface  of  the  cornea,  till 
it  shps  into  the  incision,  and  then  carries  it  rather  rapidlv  through 
the  anterior  chamber,  till  it  reaches  that  edge  of  the  iris  which  is  to 
be  separated  from  the  choroid.  The  double  hook  now  rests,  with 
its  points  directed  downwards,  in  the  angle  between  the  cornea  and 
iris.  Turning  it  a  quarter  round  on  its  axis,  and  pushing  it  to  the 
very  edge  of  the  anterior  chamber,  the  operator  by  slowly  relaxing 
his  grasp  of  the  instrument,  allows  its  two  branches  to  expand,  and 
immediatel}-  lays  hold  of  tire  edge  of  the  iris,  with  the  two  hooks, 
thus  separated  from  each  other.  He  next  closes  the  instrument,  so 
that  the  two  hooks  again  approach  each  other,  carrying  the  iris  with 
them,  and  la3'ing  hold  of  it  as  if  with  a  pair  of  forceps.  The  in- 
strument is  now  turned  again  on  its  axis,  till  the  points  of  the  dou- 
ble hook  are  directed  downwards  as  before,  and  thus  the  second  pe- 
riod of  the  operation  is  completed. 


571 

3d  Period.  Very  slowly  the  operator  now  withdraws  the  double 
hook  through  the  anterior  chamber  towards  the  incision  of  the  cor- 
nea, carrying  with  it  the  iris,  between  which,  and  the  edge  of  the 
cornea,  he  perceives  the  artificial  pupil  gradually  formed.  During 
this  period,  the  instrument  must  be  kept  as  close  to  the  cornea  as 
possible,  in  order  to  avoid  any  injury  of  the  crystalline  capsule  ;  and 
as  this  is  the  most  painful  part  of  the  operation,  care  must  be  taken 
to  keep  the  patient's  head  steady,  and  to  guard  against  his  raising 
his  hand  to  his  eye.  The  pupil,  as  it  is  formed,  fills  with  blood,  so 
that  it  is  often  impossible  to  discern  the  state  of  the  lens  and 
capsule. 

Ath  Period.  The  operator  now  lequires  to  press  the  branches 
of  the  instrument  closely  together,  and  at  the  same  time  to  depress 
the  handle,  so  that  the  convex  edge  of  the  hooks  may  slip  easily  out 
of  the  incision ;  for  if  any  difficulty  occurs  in  bringing  out  the  in- 
strument, the  operator  is  apt,  in  attempting  to  obviate  it,  to  lose  hold 
of  the  piece  of  iris  which  he  has  separated.  The  portion  to  be  pro- 
truded rarely  requires  to  exceed  the  size  of  a  pin  head.  This,  how- 
ever, must  vary  in  particular  cases  ;  for  it  sometimes  happens,  from 
the  great  extensibility  of  the  iris,  that  the  pupil  will  not  be  of  suffi- 
cient size,  unless  the  separation  is  continued  even  after  the  double 

hook  is  brouofht  out  of  the  eve  :  while  in  cases  where  the  iris  is  much 

•    ••11 
diseased  in  texture,  and  its  extensibiUty  thereby  greatly  dimuiished, 

it  is  sometimes  found  difficult  to  effect  a  protrusion  at  all.     The 

operator  must  be  cautious  of  allowing  the  branches  of  the  hook  to 

separate,  or  of  letting  go  his  hold  of  the  iris,  till  he  sees  that  he  has 

fully  accomplished  this  part  of  the  operation,  and  that  the  protrusion 

appears  to  be  retained  by  the  hps  of  the  incision,  w^hich  will  be  done 

more  effectually  by  carrying  the  protruded  portion  of  the  iris  from 

the  middle  of  the  incision  towards  either  of  its  extremities.     The 

hooks  are  then  to  be  freed  from  the  protruding  part  of  the  iris. 

In  withdrawing  the  instrument  from  the  anterior  chamber, 
should  it  happen  that  the  hooks  catch  in  the  substance  of  the  cor- 
nea, they  must  be  pushed  back  again,  and  care  taken  to  follow 
more  exactly  the  rules  above  set  down  for  this  part  of  the  operation  ; 
or  the  instrument  may  be  turned  round  on  its  axis,  the  handle 
raised,  and  the  convex  edge  of  the  hooks  brought  out  from  below. 

The  eye  should  now  instantly  be  shut,  in  order,  by  the  pressure 
of  the  lids,  to  assist  in  strangulating  the  protruding  portion  of  the 
iris.  After  a  few  minutes,  the  eye  may  again  be  opened,  in  order 
to  ascertain  the  state  of  the  prolapsus.  Should  this  have  disap- 
peared, by  the  iris  having  retracted,  which  is  not  likely  to  happen 
unless  the  incision  of  the  cornea  is  too  large,  the  instrument  ought 
to  be  re-introduced,  the  separated  part  again  brought  out,  and  to 
ensure  the  object  of  the  operation,  the  protruding  portion  snipt  oflf 
with  the  scissors,  thus  combining  excision  with  separation. 

Should  the  application  of  the  double  hook  not  effect  a  satisfacto- 
ry separation,  but  rather  tear  the  iris,  which  is  likely  to  happen 


572 

only  when  its  texture  is  much  changed  from  disease,  the  portion 
which  is  protruded  will,  in  all  probability,  be  too  small  to  remain 
fixed  in  the  wound  of  the  cornea,  and  will  be  apt  therefore  to  re- 
cede, the  consequence  of  which  will  be  that  the  pupil  will  be  too 
little,  and  will  in  general  soon  be  filled  up  by  effused  lymph.  Rei- 
singer  recommends, therefore,  under  such  circumstances,  the  excision 
of  the  protruded  part  of  the  iris. 

When  the  fibres  of  the  iris  are  in  a  state  of  unnatural  tension 
previous  to  the  operation,  as  may  happen  from  there  having  been 
a  former  protrusion  of  that  membrane  through  a  wound  of  the  cor- 
nea, or  through  a  penetrating  ulcer,  the  protruding  of  a  portion  of 
the  separated  iris  may  be  dispensed  with,  as,  in  such  a  case,  there 
is  no  danger  of  the  iris  returning  towards  the  choroid. 

When  cataract  co-exists  with  such  changes  in  the  cornea  or  iris 
as  may  demand  the  formation  of  an  artificial  pupil,  and  when  we 
attempt  this  by  the  operation  of  separation,  it  will  in  general  be 
useless,  or  even  improper,  to  attempt  any  thing  for  the  removal  of 
the  cataract  at  the  time  of  forming  the  artificial  pupil.  Extraction 
is  plainly  out  of  the  question,  and  it  would  be  better  to  defer  di- 
vision or  displacement  till  the  eye  has  recovered  from  so  severe  an 
operation  as  the  separation  of  the  iris  from  the  choroid.  Indeed 
the  flow  of  blood  into  the  aqueous  chambers,  especially  when  the 
separation  is  in  the  equator  of  the  eye,  is  in  general  so  great  as  to 
make  it  impossible  for  us  to  discern  the  parts  posterior  to  the  iris 
with  sufiicient  distinctness,  to  attempt  any  operation  on  the  lens  or 
capsule,  till  that  blood  is  absorbed. 


SECTION  VIII. COMPOUND    OPERATIONS    FOR    THE  FORMATION 

OF    AN  ARTIFICIAL  PUPIL. 

1.  The  combination  of  separation  with  excision  has  already 
been  noticed.  It  has  been  recommended  both  by  Assalini  and  by 
Reisinger,  when  the  separated  portion  of  the  iris  is  found  to  recede 
towards  the  choroid  ;  and  in  such  a  case,  there  can  be  no  question 
of  the  propriety  of  again  bringing  out  the  separated  portion  of  iris 
through  the  incision  of  the  cornea,  and  removing  it  with  the  scis- 
sors. 

2.  Another  compound  operation  was  proposed  by  Donegana,* 
namely,  separation  with  incision,  but  which  scarcely  deserves  to 
be  particularly  noticed.  The  instrument  employed  by  him  was 
a  falciform  needle,  with  which,  introduced  through  the  sclerotica, 
he  first  separated  a  portion  of  the  iris  from  the  choroid,  and  then 
endeavoured  to  divide  the  iris  from  its  circumference  towards  its 
centre.  The  latter  part  of  this  operation  it  must  be  diflicult  to 
accomplish.  Indeed,  it  is  hardly  possible  by  the  pressure  even 
of  the  sharpest  instrument,  to  effect  a  division  of  the  iris,  after  sep- 
aration has  once  commenced. 

*  Delia  Pupilla  Artificiale.    Milano,  1809. 


573 

3.  It  is  sometimes  found  advantageous  to  add  incision  to  ex- 
cision. Thus,  in  a  case  of  extensive  opacity  of  the  cornea,  with  ad- 
herent iris,  a  segment  at  the  lower  edge  of  the  cornea  remaining 
transparent,  1  first  formed  an  artificial  pupil  towards  one  extremity 
of  the  segment  by  excision,  but  regarding  it  as  too  small,  instead 
of  attempting  an  additional  excision,  I  introduced  Maunoir's  scis- 
sors, and  divided  the  iris  transversely,  so  as  to  enlarge  the  artificial 
pupil  to  a  medium  size. 


SECTION  IX. ACCIDENTS  OCCASIONALLY  ATTENDING  THE  FOR- 
MATION OF  AN  ARTIFICIAL  PUPIL.       AFTER-TREATMENT. 

Many  of  the  accidents  which  are  apt  to  attend  the  formation  of 
an  artificial  pupil,  are  similar  to  those  which  accompany  the  opera- 
tions for  cataract,  and  need  not  be  particularly  insisted  on.  A  few, 
however,  are  peculiar. 

1.  By  every  mode  in  which  an  artificial  pupil  is  formed,  blood  is 
apt  to  be  effused;  much  more  in  separation,  however,  than  in  the 
other  operations,  and  much  more  when  the  iris  is  altered  from  its 
natural  texture  in  consequence  of  inflammation.  In  separation, 
the  trunks  of  the  blood-vessels  which  nourish  the  iris  are  torn 
across,  especially  when  the  new  pupil  is  formed  towards  the  tempo- 
ral or  nasal  angle  of  the  eye ;  while  after  long-continued  inflam- 
mation, the  iris  is  thickened  and  loaded  with  blood,  ^he  bleeding 
after  separation,  and  sometimes  after  excision j  is  so  considerable, 
that  it  goes  on  for  a  few  minutes  through  the  wound  of  the  cor- 
nea. Filling  the  aqueous  chambers,  the  blood  prevents  us  from 
making  any  experiments  regarding  the  degree  of  vision  likely 
to  be  recovered  by  the  operation.  In  24  hours,  in  general,  the 
pupil  becomes  clear.  Indeed,  it  is  remarkable  with  what  celerity 
a  lai'ge  quantity  of  blood  is  absorbed  from  the  aqueous  chambers. 

2.  Little  or  no  pain  attends  incision  and  excision  ;  but  it  is 
otherwise  with  separation,  owing  to  the  tearing  across  of  the  ciliary 
nerves,  attendant  on  this  method  of  forming  an  artificial  pupil. 
The  pain  of  separation  is  always  considerable,  and  often  severe, 
rendering  necessary  the  use  of  opium  after  the  patient  is  put  to  bed. 
During  the  operation,  the  assistant  requires  to  be  on  his  guard,  lest 
the  patient  suddenly  moves  away  his  head,  when  he  feels  the  pain, 
which  might  lead  to  the  separation  of  a  much  greater  portion  of  the 
iris  than  the  operator  intended,  or  could  be  consistent  with  useful 
vision. 

3.  Should  the  operator  find  that  he  has  formed  too  small  a  pupil 
to  be  very  useful,  he  ought  immediately  to  enlarge  it,  either  by 
repeating  the  operation  which  he  has  been  performing,  or  by  con- 
verting it  into  some  of  the  compound  operations  described  in  the 
last  section.  It  must  be  observed,  however,  that  an  artificial  pupil 
will  often  appear  small  immediately  after  it  is  formed,  and  while 
the  eye  is  drained  of  aqueous  humour,  which,  after  the  eye  becomes 
plump  again,  will  be  found  of  fully  a  medium  size. 


574 

4.  When  too  large  an  artificial  pupil  has  been  formed,  so  that 
the  eye  is  dazzled  even  by  moderate  light,  it  is  necessary  that  the 
patient  should  shade  the  eyes,  or  wear  a  piece  of  pasteboard  or  hght 
wood,  concave  within  and  convex  without,  blackened  on  both  sides, 
and  pierced  in  the  centre  with  a  round  hole  of  the  size  of  the  natu- 
ral pupil.  This  will  enable  him  to  see  at  least  all  large  objects,  al- 
though he  will  probably  be  unable  to  distinguish  small  ones  even 
with  the  aid  of  this  contrivance. 

5.  The  treatment  of  patients  who  have  undergone  an  operation 
for  artificial  pupil,  has  reference  chiefly  to  the  danger  of  inflamma- 
tion coming  on  in  the  eye,  and  especially  internal  inflammation. 
The  patient  for  some  days  must  remain  in  bed,  his  eyes  excluded 
from  bright  light,  and  his  diet  strictly  antiphlogistic.  Belladonna 
may  be  applied  when  the  pupil  has  been  formed  by  incision  or  ex- 
cision, but  ought  to  be  avoided  (at  least  immediately)  after  separa- 
tion. Should  pain  in  the  eye,  or  round  the  orbit,  supervene,  vene- 
section ought  freely  to  be  used,  and  followed  up  by  the  application 
of  leeches.  Calomel  with  opium  ought  instantly  to  be  begun, 
in  such  doses  as  are  likely  speedily  to  affect  the  mouth,  and  con- 
tinued till  all  danger  of  iritis  appears  past.  The  inflammation 
excited  by  an  operation  for  artificial  pupil  often  partakes  of  the 
strumous  character,  and  not  unfrequently  is  strumo-catarrhal. 
Depletion,  in  such  cases,  does  not  require  to  be  carried  to  the 
same  extent  as  when  the  inflammation  is  internal ;  and  much 
benefit  will  be  derived  from  the  administration  of  the  sulphate  of 
quina. 

6.  The  degree  of  vision  recovered  by  the  formation  of  an  arti- 
ficial pupil  necessarily  varies  according  to  the  condition  of  the  eye 
which  has  been  operated  on,  the  kind  of  pupil  which  has  been 
formed, _and  the  success  which  has  attended  the  operation.  If  the 
lens  has  been  removed  either  before  the  formation  of  the  artificial 
pupil,  at  the  same  time,  or  afterwards,  cataract-glasses  will  be  re- 
quired. If  the  patient  is  short-sighted  or  long  sighted,  but  the  lens 
entire,  he  will  still  be  obliged  to  employ  concave  or  convex  specta- 
cles. So  far  as  any  other  sort  of  imperfect  sight  is*  concerned,  no 
glass  will  be  of  any  use  to  him. 

It  often  happens,  that  they  in  whom  an  artificial  pupil  has  been 
formed,  present,  in  the  first  instance,  but  very  dubious  signs  of 
sensibility  of  the  retina ;  so  much  so,  that  the  operator  may  be  led 
almost  to  despair  of  a  restoration  to  sight.  I  have  known  a  fort- 
night elapse  after  all  signs  of  inflammation  had  subsided,  before 
the  patient  could  tell  one  finger  from  another,  and  yet  very  tolerable 
vision  be  recovered. 


575 


CHAPTER  XVI. 

PRETERNATURAL  STATES  OF  THE  IRIS,  INDEPENDENT  OF 
INFLAMMATION. 

SECTION  I. MYOSIS.* 

Contraction  of  the  pupil,  with  immobilityj  appears  to  be  one  of 
the  man)?  changes  which  the  eye  undergoes  from  old  age.  This 
state  is  also  sometimes  met  with  in  middle  hfe,  and  is  known  by 
the  name  of  myosis. 

Syraftoms.  The  pupil  is  very  considerably  below  the  medium 
size,  perfectly  regular,  extremely  limited  and  slow  in  its  motions, 
scarcely  dilating  at  all  when  the  patient  passes  into  a  dark  place, 
and  yielding  little  even  to  the  influence  of  belladonna.  The  pa- 
tient's vision  is  obscure,  especially  in  weak  light,  in  some  cases  he 
sees  only  during  certain  hours  of  the  day,  and  when  the  myosis  is 
complete,  he  is  almost  totally  blind.  The  complaint  is  attended  by 
pains  in  the  head,  especially  in  the  forehead  ;  and  the  subjects  of 
this  disease  are,  in  general,  debilitated  or  cachectic  individuals. 

Proximate  cause.  This  is  in  fact  unknown ;  but  has  been 
supposed  to  be,  in  some  cases,  of  a  spasmodic  nature,  and  in  others, 
paralytic.  Thus  Plenck  admits  a  spasmodic  myosis,  accom- 
panying hysterical  and  other  nervous  diseases,  and  attributable  to 
spasm  of  the  orbicular  fibres  of  the  iris ;  and  a  paralytic  myosis, 
arising  from  palsy  of  the  straight  fibres,  and  attendant  on  paralytic 
diseases.! 

It  is  worthy  of  observation,  that  contraction  is  the  natural  state 
of  the  pupil  during  sleep.J  Facts  also  are  recorded,  leading  to  the 
conclusion,  that  under  the  influence  of  a  full  dose  of  opium,  and 
even  of  belladonna,  the  pupil  becomes  greatly  contracted. §  In 
apoplexy,  too,  the  pupil  has  been  found  gradually  to  contract,  till 
at  last,  when  the  patient  has  become  perfectly  insensible,  all  vol- 
untary power  having  left  him,  the  heart  acting  almost  alone,  and 
respiration  being  performed  slowly  and  imperfectly  by  the  dia- 
phragm, the  pupil  has  been  observed  to  form  an  extremely  small 
aperture.  II 

The  probabihty  is,  that  myosis  does  not  so  much  depend,  in 
general,  on  any  disease  direcily  affecting  the  substance  of  the  iris, 

*  Prom  fjLvo),  to  shut. 

t  De  Morbis  Oculorum,  p.  120.  Viennae,  1777.  The  same  notion  was  promul- 
gated by  Mauchart,  in  his  dissertation  De  Pupillce  Phthisi. 

t  Fontana  del  Moti  dell'  Iride.  Lucca,  1765. — Janin,  Memoires  et  Observations 
sur  I'CEil,  p.  8.  Lyon,  1772. — Cuvier,  Le9ons  d' Anatomic  Comparee.  Tome  ii.  p. 
409.     Paris,  1805. 

§  On  the  Muscularity  of  the  Iris ;  by  John  Dalrymple ;  in  the  Journal  of  Morbid 
Anatomy.     Vol.  i.  p.  61.    London,  1828. 

II  Ibid.  p.  64. 


576 

as  on  some  morbid  change  of  the  nerves  by  which  this  membrane 
is  animated  and  excited  to  motion ;  and  hence,  in^certain  cases, 
myosis  comes  to  be  conjoined  with  amaurosis. 

Exciting  causes.  Frequent  and  long-continued  employment 
of  the  eyes  in  the  examination  of  minute  objects,  especially  of  those 
which  reflect  the  light  strongly,  induces  a  habitual  contraction  of 
the  pupil ;  and  this  ends  in  an  inability  of  this  aperture  to  expand, 
even  when  the  eyes  are  exposed  to  feeble  light.  Those  who  read 
or  write  much  by  candle  light,  embroiderers,  watchmakers,  setters 
of  jewels,  and  the  like,  are  thus  exposed  more  [thanjothers  to 
myosis. 

Treatment.  The  few  well-marked  cases  of  this  disease  which 
have  fallen  under  my  observation,  appeared  to  be  scarcely  at  all 
benefited  by  any  mode  of  treatment.  Temporary  dilatation  of 
the  pupil  by  belladonna  only  increased  the  weakness  of  sight  by 
which  the  myosis  was  accompanied.  Antispasmodic  and  antipar- 
alytic  remedies  are  recommended  in  the  treatment  of  this]  disease  ; 
but  probably  more  good  w^ill  be  effected  by  carefully  guarding 
against  the  exciting  causes  of  the  disease,  than  by  medicines  of  any 
kind.  The  eyes  should  be  shaded ;  reading,  writing,  and  similar 
laborious  occupations  of  the  sight,  should  be  avoided  ;  exercise  in 
the  country  should  be  enjoined  ;  and  the  patient  should  retire  to 
rest  at  an  early  hour. 


SECTION  II. — MYDRIASIS.* 

A  preternatural  dilatation  of  the  pupil  is  styled  mydriasis  ;  the 
pupil,  in  general,  no  longer  contracting,  even  although  the  eye  be 
directed  to  a  near  object,  or  exposed  to  a  bright  light.  Yery  fre- 
quently, this  is  merely  one  of  the  symptoms  of  certain  kinds  of 
amaurosis  :  such  as,  the  hydrocephalic.  But,  occasionally,  it  would 
appear  that  mydriasis  occurs  independently  of  any  other  affection, 
and  when  this  is  the  case,  the  dilatation  sometimes  proceeds  to 
such  a  degree,  that  only  a  narrow  rim  of  iris  remains  in  view.  Of 
course,  in  this  state  of  the  pupil,  the  eye  is  so  much  dazzled  by 
the  uncontrolled  influx  of  light,  that  the  patient  is  unable/especially 
in  broad  day,  to  look  steadily  at  any  object,  or  to  discern  any 
thing  with  distinctness.  He  sees  objects  apparently  confused,  and 
sometimes  they  seem  smaller  than  natural.  He  is  more  deficient 
in  the  perception  of  near  than  of  remote  objects.  By  looking 
through  a  hole  in  a  card,  however,  the  vision  of  the  eye  afiected 
with  mydriasis  is  greatly  improved  ;  in  some  cases,  the  improve- 
ment is  such  that  the  patient  is  even  able  to  read!;  and  this  fact 
constitutes  one  of  the  chief  grounds  of  diagnosis  between  the  sym- 
pathetic dilatation  of  the  pupil  which  attends  amaurosis,  and  idio- 
pathic mydriasis.     Demours  had  never  seen  mydriasis  in  both  eyes. 

*  From  a./j.uiS'^o;,  obscure  j  or  from  juvJ'itai,  to  abound  in  moisture,  because  it  was 
thought  to  depend  on  redundant  moisture. 


577 

Causes.  Different  species  of  idiopathic  mydriasis  have  been  dis- 
tinguished by  authors  ;  such  as,  the  paralytic,  arising  from  palsy 
of  the  supposed  sphincter  fibres  of  the  iris,  and  the  spasmodic,  from 
spasm  of  the  straight  fibres.  The  mydriasis  which  follows  the  ap- 
plication of  belladonna,  and  some  similar  narcotics,  and  of  which 
so  much  advantage  is  taken  in  the  treatment  of  inflammation  of 
the  iris,  and  in  certain  operations  for  cataract,  is  generally  regarded 
as  paralytic ;  but  it  is  evident  that  this  is  entirely  a  gratuitous  as- 
sumption. A  frequent  cause  of  mydriasis  is  the  passage  of  a  large 
cataract  through  the  pupil  in  the  operation  of  extraction.  Preter- 
natural distension  is  supposed  in  this  instance  to  give  rise  to  atony 
of  the  iris,  which,  generally  after  a  few  days,  wears  off,  so  that  the 
pupil  "contracts  to  its  former  diameter.  Blows  on  the  eye,  and  other 
injuries,  sometimes  induce  mydriasis,  without  any  affection  of  the 
optic  nerve.  Rarely  is  it  the  case,  that  any  signs  of  cerebral  disor- 
der are  attendant  on  simple  dilatation  of  the  pupil.  Mr.  Ware  ob- 
serves, that  most  of  the  persons  with  mydriasis  whom  he  had  seen, 
had  been  debilitated  by  fatigue  or  anxiety  before  the  disease  of  the 
eye  was  discovered ;  and  that  in  some,  it  had  been  preceded  by 
affections  of  the  stomach  and  alimentary  canal. 

To  mydriasis,  amaurosis  is  sometimes  superadded.  In  other 
cases,  amaurosis  has  been  known  to  attack  an  eye  which  had  been 
cured  of  mydriasis. 

We  are  as  unable  to  explain  the  proximate  cause  of  mydriasis  as 
of  myosis.  Both  probably  depend  on  some  peculiar  change  affect- 
ing the  ophthalmic  ganglion  or  the  ciliary  nerves. 

Cases.  We  are  indebted  to  Dr.  Wells  and  Mr.  Ware  for  two  in- 
teresting cases  of  mydriasis. 

Case  1.  Dr.  Wells  was  consulted  by  a  gentleman,  about  35  years 
of  age,  very  tall,  and  inclining  to  be  corpulent,  who,  about  a  month 
before,  had  been  attacked  with  a  catarrh,  and  as  this  was  leaving 
him,  was  seized  with  a  shght  stupor,  and  a  feehngof  weight  in  his 
forehead.  He  began  at  the  same  time  to  see  less  distinctly  than 
formerly  with  his  right  eye,  and  to  lose  the  power  of  moving  its 
upper  lid.  The  pupil  of  the  same  eye  was  also  observed  to  be  much 
dilated.  In  a  few  days,  the  left  eye  became  similarly  affected  with 
the  right,  but  in  a  less  degree.  Previous  to  this  ailment,  this  pa- 
tient's sight  had  always  been  so  good,  that  he  had  never  used  glasses 
of  any  kind  to  improve  it.  On  examining  the  eyes,  Dr.  Wells 
could  not  discover  in  them  any  other  appearance  of  disease,  than 
that  their  pupils,  the  right  particularly,  were  much  too  large,  and 
that  their  size  was  little  affected  by  the  quantity  of  light  which 
passed  through  them.  At  first,  he  thought  that  their  dilatation  was 
occasioned  by  a  defect  of  sensibihty  in  the  retinae  ;  but  he  was  quick- 
ly obliged  to  abandon  this  opinion,  as  the  patient  assured  him,  that 
*his  sensation  of  light  was  as  strong  as  it  had  ever  been  during  any 
former  period  of  his  life.  Dr.  Wells  next  inquired,  whether  objects 
at  different  distances  appeared  to  him  equally  distinct.  He  answer- 
73 


578 

edj  that  he  saw  distant  objects  accurately,  and  in  proof  told  what 
the  hour  was  by  a  remote  public  clock  :  but  be  added,  tbat  the  let- 
ters of  a  book  seemed  to  him  so  confused,  that  it  was  witb  difficulty 
he  could  make  out  the  words.     He  was  now  desired  to  look  at  a 
page  of  a   printed  book,  through  spectacles  with  convex  glasses. 
He  did  so.  and  found  that  he  could  read  it  with  ease.     "  From  these! 
circumstances.'*  observes  Dr.  Wells.  "  it  wms  veiy  plain,  that  thiaj 
gentleman,  at  the  same  time  tbat  his  pupils  had  become  dilated,  and' 
hk  upper  eyelids  paralytic,  had  acquired  the  sight  of  an  old  man,  by 
lotsiDg  suddenly  the  command  of  the  muscles,  by  which  the  eye  is 
enaJded  to  see  near  objects  distinctly  ;  it  being  known  to  those,  who 
are  conversant  with  the  facts  relating  to  human  vision,  that  the  eye 
in  its  relaxed  state  is  fitted  for  distant  objects,  and  that  the  seeing 
of  near  objects  accurately,  is  dependent  upon  muscular  exertion.''* 

Case  2.  Mr,  Ware  has  recorded  the  case  of  a  lady,  between  30 
and  40  yeais  of  age,  the  pnpil  of  whose  right  eye,  when  she  was 
not  engaged  in  reading,  or  in  working  with  her  needle,  was  always 
dilated  very  nearly  to  the  lim  of  the  cornea ;  but  whenever  she 
looked  at  a  small  object,  nine  inches  from  the  eye,  it  contracted 
within  less  than  a  minute,  to  a  size  nearly  as  small  as  the  head  of 
a  pio-  Her  left  pupil  was  not  affected  hke  the  right ;  but  in  every 
degree  of  light  and  distance,  was  contracted  rather  more  than  is 
usual  in  other  persons.  The  vision  was  not  precisely  ahke  in  the 
two  eyes  ;  the  right  eye  being  in  a  small  degree  near-sighted,  and 
receiving  assistance  from  the  first  number  of  a  concave  glass,  where- 
as the  left  eye  derived  no  benefit  from  it.  The  remarkable  dilata- 
tion of  the  pupil  of  the  right  eye  had  existed  for  twenty  years.  A 
fariety  of  remedies  had  been  employed  at  different  times  to  correct 
it,  bat  none  of  them  had  made  any  alteration. 

Mr.  Ware  mentions  particularly,  that  in  order  to  produce  the  con- 
traction of  the  dilated  pupil,  in  this  case,  the  object  looked  at  required 
to  be  placed  exacdy  nine  inches  from  the  eye.  If  it  were  brought 
nearer,  it  had  no  more  power  to  produce  the  contraction, than  if  it 
were  placed  at  a  remoter  distance.  It  was  also  observed,  that  the 
ctmtinuance  of  the  contraction  of  the  pupil  depended,  in  some  de- 
gree, on  the  state  of  the  lady's  health  ;  since,  although  the  contrac- 
tion never  remained  long  after  the  attention  was  withdrawn  from  a 
near  object,  yet,  whenever  the  patient  was  debihtated  by  aoy  tem- 
porary ailment,  the  contraction  was  of  much  shorter  duration  than 
when  her  health  was  entire.! 

Frog-ttosis.  DemourSjl  who  appears  to  write  on  mydriasis  fully 
more  from  experience  than  most  other  authors,  pronounces  rather  a 
favourable  prognosis  in  this  disease.  He  says,  that  when  it  has  not 
been  the  effect  of  a  contusion  or  serious  wound  of  the  eye,  he  has 
generally  seen  it  yield,  and  diminish  one  half  in  the  space  of  the 

*  Pluloei^Iucal  Transactions,  toL  ci.  p.  378.     London,  ISll. 

+  PhiloBaphical  Transactions,  vol.  ciii.  p.  36.  London,  1S13. 

t  Traite  des  Maladies  des  Yeas.     Tome.  i.  p.  444.    Paris,  1818. 


679 

fir?L  six  months,  even  in  those  who  employed  no  means  of  cure. 
^Vhat  remains  of  the  disease  disappears  mnch  more  slowly.  He 
had  witnessed  complete  restoration  of  the  pupil  to  its  natural  size, 
even  after  a  contusion  of  the  eye  ;  although  in  such  cases  recovery 
is  extremely  rare.  The  result  of  his  observations  was,  that  seven 
cases  out  of  nine  proceed  towards  a  cure,  even  without  any  treat- 
ment :  and  that  httle  more  can  be  done  than  to  accelerate  the  cure, 
chiefly  by  the  use  of  external  stimulants. 

Treatment.  The  remedies  which  have  been  found  most  useful 
in  mydriasis  are  blood-letting  and  a  spare  diet,  followed  by  such 
applications  as  are  likely  to  excite  contraction  of  the  pupil.  De- 
mours  remarks,  that,  if  any  acrid  liquid  is  dropped  upon  an  eye 
affected  with  this  disease,  even  although  the  dilatation  of  the  pupil 
!  has  been  carried  to  the  utmost  degree,  that  aperture  instantly  con- 
tracts nearly  one  half,  and  the  patient  recovers  for  a  minute  or  two 
the  power  of  seeing  such  minute  objects  as  previously  he  has  been 
able  to  distinguish  only  by  looking  through  a  hole  in  a  card,  or 
similar  small  opening.  The  stimulating  practice  followed  by  De- 
mours  consists  in  directing  small  electric  sparks  against  the  eye, 
then  rubbing  it  gently  for  about  half  a  minute  with  the  end  of.  a 
silver  probe  bent  into  the  form  of  a  ring,  and  immediately  after- 
wards dropping  in  upon  it  a  cold  infusion  of  tobacco. 

M.  Serret,  of  Uzes,  has  ventured  to  treat  mydriasis,  (or,  as  he 
terms  it,  idiopathic  paralysis  of  the  iris,  without  affection  of  the 
retina  and  optic  nerve.)  by  the  apphcation  of  nitrate  of  silver  to  the 
cornea  near  its  junction  with  the  sclerotica,  and  has  found  this  a 
more  powerful  and  useful  excitant  than  the  means  recommended 
by  Demours.  In  a  memoir  presented  to  the  Royal  Academy  of 
Medicine,  he  related  four  cases,  in  illustration  of  the  success  of  his 
method,  and  the  committee  of  the  Academy  to  whom  ihe  subject 
was  referred,  found  the  apphcation  of  the  caustic,  in  the  manner 
directed  by  M.  Serres,  efficacious  in  three  other  instances.  The 
caustic  should  be  applied  for  one  second.  It  is  useful  that  some 
lacrymation  should  be  excited  by  the  application,  and  that  it  should 
be  followed  l^y  a  slight  injection  of  the  vessels  of  the  conjunctiva. 
The  slight  cloud  which  appears  on  the  cornea  rarely  continues 
above  a  few  days.  The  committee  of  the  Academy  observed  that 
this  means  of  cure,  totally  useless  in  amaurosis,  could  be  of  service 
only  in  those  idiopathic  palsies  of  the  iris  arising  from  an  affection  of 
the  ciliary  nerves,  or  of  the  other  branches  of  the  3d  and  5th  pairs.* 


SECTION  III. TREMULOUS   IRIS. 

The  cases  in  which  the  iris  is  affected,  on  every  movement  of 
the  eye,  with  a  pecuhar  tremulous  or  undulatory  motion,  are  very 
various,  and  by  no  means  unfrequent.     The  texture  of  the  iris,  in 

*  Archives  Generales  de  Medecine.     Tome  xTii.  p.  307.    Paris,  1828. 


CHAPTER  XVII. 
GLAUCOMA  AND  CATS-EYE. 

SECTION    I. GLAUCOMA. t 


580 

such  cases,  is  apparently  uninjured,   and  the  pupil  generally  of  its 
natural  fonn  ;  but  the  membrane  seldom  appears  to  retain  almost  ■ 
any  power  of  contracting  or  expanding.     I  have  seen  it,  however, 
from  sympathy  with  the  pupil  of  the  other  eye,  which  was  healthy, 
move  briskly  and  extensively. 

This  state  of  the  iris  is  frequently,  but  not  necessarily,  connected 
with  amaurosis.  We  meet  with  it  combined  with  cataract,  and 
especially  with  capsulo-lenticular  cataract.  It  often  results  from  a 
blow  on  the  eye,  and  in  this  case  is  generally  attended  by  partial 
or  complete  insensibility  of  the  retina,  and  opacity  of  the  lens.  In 
those  born  amaurotic,  or  affected  with  congenital  cataract,  trem- 
ulousness  of  the  iris  is  often  met  with  ;  and  in  such  subjects,  it  is 
attended  by  oscillation*  of  the  eyeball.  When  this  disease  of  the 
iris  is  combined  with  cataract,  the  latter  not  unfrequently  partakes 
of  the  tremulous  motion.!  After  operations  for  cataract,  and  es- 
pecially after  operations  on  eyes,  the  vitreous  humour  of  which  has 
been  found  dissolved,  or  from  which  a  considerable  quantity  of  the 
vitreous  humour  has  been  evacuated,  the  iris  frequently  presents 
this  undulatory  motion. 

In  all  cases  of  tremulous  iris,  there  appears  to  be  a  larger  quan- 
tity of  aqueous  fluid  in  the  posterior  chamber  than  natural,  and, 
in  many  of  them,  the  whole  cavity  behind  the  iris  is  filled  with 
fluid,  in  consequence  of  dissolution  of  the  hyaloid  membrane.  The 
fibres  of  the  ii-is  being  probably  paralytic,  the  membrane  hangs 
loose,  and  is  unable  to  resist  those  undulations  of  the  aqueous  hu- 
mour which  take  place  whenever  the  eye  is  turned  from  one  side 
to  another  by  the  action  of  the  recti  muscles.  It  is  then  only,  in 
fact,  that  the  tremulousness  of  the  iris  is  perceptible.  We  do  not 
observe  it  so  long  as  the  patient  fixes  his  attention  on  the  same 
object,  nor  does  the  attempt  to  accommodate  the  eye  to  objects 
placed  at  a  variety  of  distances,  but  in  the  same  right  line,  appear 
to  produce  the  motion  in  question. 

This  affection  of  the  iris  has  hitherto  been  regarded  as  incurable, 
and  certainly  it  affords  an  unfavourable  index  of  the  state  of  the 
vitreous  humour  and  retina. 


It  is  evident  that  Hippocrates  comprehended  under  this  term  every 
sort  of  opacity  which  appeared  behind  the  pupil.     Thus,  in  enu- 

*  See  page  222.  t  See  page  476. 

t  TKa.vKMfx<t  and  yKtuiiuetrii,  from  yKst.vx.oc,  blue,  green,  or  grey ;   because  of  the 
greyish,  bluish,  or  greenish  appearance  of  the  pupil. 


581 

merating  the  diseases  to  which  man  is  exposed  at  different  periods 
of  life,  he  mentions,  along  with  others  to  which  old  age  is  subject, 

evidently  employing  the  term  yxavycua-m  to  signify  rather  a  class  of 
diseases  than  any  single  affection  of  the  transparent  parts  of  the 
eye.  The  appearances  arising  from  effusion  of  lymph  into  the 
pupil,  or  what  we  now  term  spurious  cataract,  are  no  doubt  very 
different  from  those  presented  by  capsular  or  lenticular  opacity ; 
and  these,  in  their  turn,  are,  in  general,  readily  discriminated  from 
the  signs  of  an  apparent  opacity  still  deeper  in  the  e5^e.  We, 
who  have  the  advantage  of  knowing,  by  dissection,  the  differences 
of  these  three  kinds  of  disease  which  affect  the  transparent  media 
of  the  eye,  need  not  be  surprised  that  they  were  not  accurately 
distinguished  by  the  father  of  medicine,  who,  though  he  did  not 
fail  to  observe  that  the  m^oci  yXavKoviJumi  presented  various  colours 
and  forms  in  different  cases,  that  this  class  of  diseases  of  the  eye 
arose  from  a  variety  of  causes,  and  that  some  of  these  diseases 
were  more  destructive  of  vision  than  others,!  had  probably  enjoyed 
no  opportunity  of  ascertaining,  after  death,  the  nature  of  those 
changes  upon  which  the  yXa.vMxrit^;  depended ;  nor  had  he  the 
advantage  of  knowing  that  some,  at  least,  of  these  diseases  could 
be  removed  by  operation,  and  in  this  way  vision  be  restored. 

It  is  uncertain  by  whom,  or  at  what  period,  the  term  vttoxvimi,  or 
itTToyjo'TKi  was  first  employed  to  signify  a  particular  species  of  opacity 
behind  the  pupil.  That  it  had,  in  a  great  measure,  superseded 
the  generic  appellation  employed  by  Hippocrates,  is  evident  from 
the  manner  in  which  Celsus  introduces  this  subject  to  our  notice, 
and  from  his  total  omission  of  yXce.vyt.u(A.a  or  yXavKua-K;.  "  Suffusio 
quoque,  quam  Grseci  vvroxva-tv^  noininant,  interdum  oculi  potentiee 
qua  cernit,  se  opponit."  I  Suffusio,  here,  is  nothing  more  than  a 
translation  of  uTox,v<ni;^  and  expresses  some  conjectural  and  un- 
founded notion  winch  the  Greeks  had  adopted  regarding  the  na- 
ture of  cataract.  They  did  not  know  that  this  disease  is,  in  gene- 
ral, nothing  more  than  a  change  in  the  transparency  and  colour 
of  a  natural  part  of  the  eye,  namely,  the  crystalline  lens.  On 
the  contrary,  they  had  been  taught,  (probably'  by  Herophilus), 
that  the  lens  was  the  immediate  organ  of  vision  ;  §  and,  therefore, 
they  were  led  to  ascribe  the  disease,  which  they  found  to  prevent 
vision  till  it  was  removed  by  surgical  operation,  to  a  suffusion 
merely  of  some  new  or  morbid  substance  between  the  iris  and  the 
lens. 

*  Aphorismorun  Sect.  iii.  31. 

t  AJ  (Te  xog£t/  yXAvitovfMVitt,  «  a.gyvgoiiS'tii  yno/nivm,  «  xvaviai,  ouJev  ^gna-rov.  TouTsav 
(fe  ci'Kiytu  A/nitvov;,  OMO-cti  »  o-^/xgoT6ga«  pa/vovra/,  h  ivguTiga.t,  »  ymiicLQ  i^oua-tst.t,  tiT  tx.  Tgo- 
(fixcrtcev  toiav  icti  yivoittTo,  in  cLvTOfActTiti      PrcecUctionum  Lib.^ii.  28. 

t  De  Re  Medica  :  Lib.  vi.  cap.  iii.  sect.  2. 

§  Sub  his  gutta  humoris  est,  ovi  albo  similis,  a  qui  videndi  facultas  proficiscitur : 
K^ua-TAKAoiiSm  a  Grsecis  nominatur.  Celsus  de  Re  Medica  ;  Lib.  vii.  pars  ii.  cap.  i. 
sect.  ii. 


582 

Although  the  diversity  of  opacities,  which  occur  behind  the  pupO, 
had  either  not  attracted  the  attention  of  Celsus,  or  was  deemed  by 
him  unworthy  of  notice,  or  had  not  been  particularly  insisted  upon 
by  the  Greek  authors  from  whom  he  copied,  the  Greeks  of  the 
second  century  were  well  aware  that  the  opacities  seen  through  the 
pupil  were  very  different  in  different  cases,  and  that  only  some  of 
them  were  susceptible  of  a  cure  by  operation.  Those  which  were 
generally  incurable,  they  distinguished  by  the  name  yXavyMjM.ra,'^ 
while  on  the  more  favourable,  they  bestowed  that  of  uTro^vi^ara. 
They  also  came  to  the  conclusion  (a  very  false  one,  no  doubt)  that 
the  former  set  of  opacities  depended  on  a  change  of  colour  and  con- 
sistence in  the  cr}-stalline  lens,  but  that  the  latter  were  to  be  attri- 
buted to  the  accumulation  of  a  new  substance,  suffused  between 
the  iris  and  the  crystalline.  Abundant  proof  could  be  brought  that 
these  were  the  opinions  of  Rufus  *  and  of  Galen  ;  t  and,  if  it  were 
necessary,  we  might  trace  these  opinions  through  the  writings  of 
Oribasius,  Aetius,  Paulus,  Actuarius.  and  a  crowd  of  others,  down 
to  the  time  of  Brisseau.  Even  Maitre-Jan,  to  whom  we  are,  in  a 
great  measure,  indebted  for  establishing,  by  dissection,  the  fact,  that 
cataract  is,  in  general,  an  opacity  of  the  crystalline  lens,  and  not  a 
filmy  suffusion  between  that  body  and  the  iris,  still  maintained  that 
glaucoma,  also,  was  a  disease  of  the  lens — "  une  alteration  toute 
particuliere  du  cristallin,  par  laquelle  il  se  desseche,  diminue  en 
volume,  change  de  couleur  et  perd  sa  transparence,  en  conssrvant 
sa  figure  naturelle,  et  devenant  plus  solide  quil  ne  doit  etre  natu- 
rellement."  + 

Preceded  by  Rolfink,  Borel,  and  others,  in  the  discovery,  that 
the  most  common  kind  of  cataract  has  its  seat  in  the  crystalline 
lens,  (a  discovery,  however,  which  he  confirmed  by  many  valuable 
observations),  Brisseau  §  appears  to  have  been  the  first  to  announce 
to  the  profession  the  opinion,  which,  from  that  day  to  this,  they 
have  ahuost  universally  adopted,  that  while  cataract  or  v7rox.viMc 
was  an  opacity  of  the  lens,  yA«j;/,&^,i«*  was  a  similar  affection  of  the 
vitreous  humour — an  opacity  deeply  seated  in  the  eye,  frequently 
of  a  bluish  or  greenish  colour,  and  visible  through  the  transparent 
lens.     He  had  been  led  to  this  opinion  partly  from  what  had  been 

*  GLuoting  from  Ruftis,  Oribasius  observes,  "  Glaucoma  et  suffusionem  veteres 
unum  eundemque  morbum  esse  existimarunt  :  posteriores  vero  glaucomata  humoris 
glacialis,  qui  ex  proprio  colore  in  glaucum  convertatur,  et  mutetur,  morbum  esse  pu- 
taverunt :  suffusionem  vero  esse  effusionem  humorum  inter  uveam  et  crj'stalloidem 
tunicam  concrescentium :  cseterum  glaucomata  omnia  curationem  non  recipiunt: 
suffusiones  vero  recipiunt,  sed  non  omnes."  Oribasii  Sj'nopseos  Lib.  ^-iii.  Cap.  47. 
Rasario  interprete.     Basileae,  1557. 

t  Ksu  y^g  KO-i  TAVT  iignrcti  Trg'jd-^it,  KAi  ui  auTc  TO  y.m^'noxctifiQ  '^yi^v,  to  Tr^an'-ii  uttiv 
cgysLvcv  T«c  o-^ia;.  ri'juii^ici  ifayxgya;  to.  K-iXou/UiysL,  wg:c  rmv  utrgai-)  vTro'/jJiA.-xTa.,  jjLi^a. 
jUsv  (5-TJt//6vst  Tcu  xgi/iTTa^.Ass/Jct/;,  t/'j-gcw,  xa/ TC!/ ;t5§iTC£;iri:/c  ;^/Ttt-voc.        *  *  * 

X5U  ai'c  TO  TTub-f^/xa.,  tc  W|sc  toiv  WT^av  o-i'^fx^^oy-a^^y  yXiVKcertc,  ^n^orn;  n.&  io-Tt, 

K3U  Tryi^ii  A/jiiTgo;  Tsy  x.gva-Ta.kKiiiiicuc  lygcu.     Fa^jivsi/  Trigt  Xgitxs  TOiv  Moptttv,  Aoy:(  u 

t  Traite  des  Maladies  de  I'GEil,  p.  ■2-23.    Trojes,  1711. 

§  Traite  de  la  Cataracte  et  du  Glaucoma.     Paris,  1709. 


583 

detected  on  dissecting  the  eyes  of  Bouidelot,  physician  to  Louis 
XIV.  who,  having  been  the  subject  of  a  disease  pronounced  to  be 
cataract,  left  orders  that  his  eyes  should  be  examined  after  death 
in  order  to  throw  some  light,  if  possible,  on  the  much  agitated 
question,  whether  cataract  was  a  film  occupying  the  posterior 
chamber,  or  an  affection  of  the  crystalline  lens.  The  dissection 
was  performed  by  Marechal.  The  lens  in  the  right  eye,  with 
which,  for  many  years,  the  patient  had  been  scarcely  able  to  dis- 
tinguish light  from  darkness,  was  found  to  be  totally  opaque  ;  its 
exterior  lamellae  were  less  solid  than  the-  interior,  forming,  as  it 
were,  a  whitish  membrane  of  about  half  a  line's  thickness,  which 
included  a  nucleus  of  more  solid  consistence,  and  of  a  yellowish 
colour.  Immediately  behind  the  fossula,  which  contained  this 
lens,  the  vitreous  humour  was  also  opaque  to  the  depth  of  more 
than  a  line,  and  tinged  of  a  yellow  colour,  although  not  to  the 
same  degree.  The  left  eye,  with  which  Bourdelot  had  continued 
to  see  with  tolerable  distinctness,  had  begun  to  be  affected  in  a 
similar  way ;  for  the  lens  had  already  lost  much  of  its  natural 
transparency,  and  the  vitreous  humour,  in  contact  with  it,  was 
slightly  yellow.  Brisseau  drew  the  conclusion  from  this  dissection, 
that,  in  such  cases,  the  complication  of  diseases  would  necessarily 
render  abortive  any  attempt  to  restore  sight  by  operation  ;  that 
although  the  lens  were  couched,  the  opacity  of  the  vitreous  humour 
would  still  continue,  and  be  sufficient  to  impede  the  passage  of  the 
rays  of  light  to  the  retina.  He  considered  himself  also  justified  in 
claiming  for  this  opacity  of  the  vitreous  humour  the  name  of  glau- 
coma.* 

Brisseau,  moreover,  having  demonstrated  to  his  full  satisfaction 
that  cataract  was  an  opacity  of  the  lens,  was  naturally  led  to  the 
conclusion  that  the  vitreous  humour  was  subject  to  a  similar  affec- 
tion, from  the  well  ascertained  fact,  that  the  disease  called  glauco- 
ma was  altogether  incurable  by  operation,  which  could  not  have 
been  the  case,  had  it  consisted,  as  was  generally  pretended,  in  a 
desiccation  and  change  of  colour  of  the  lens.  Had  glaucoma  re- 
sided in  the  lens,  it  would  have  been  cured  by  the  operation  of  de- 
pression ;  but  as  it  was  notorious  that  this  operation  did  not  cure 
glaucoma,  the  conclusion  necessarily  was  that  this  was  a  disease 
of  some  other  part  of  the  eye.  Brisseau  fixed  upon  the  vitreous 
humour  as  its  seat,  partly  vindicated,  no  doubt,  in  doing  so,  by  the 
above  mentioned  dissection  by  Marechal. 

The  appearances,  also,  which  are  presented  by  the  eye  affected 
with  glaucoma,  are  well  calculated  to  impose  upon  the  observer,  and 
lead  him  to  conclude  that  he  is  looking  through  a  transparent  lens 
.  at  an  opaque  vitreous  humour.  The  opacity  always  appears  to  be 
more  deeply  seated  than  the  lens ;  more  so,  however,  in  the  com- 
mencement of  the  disease  than  after  it  has  continued  for  some  time. 

*  Heister  de  Cataracta,  Glaucomate,  et  Amaurosi,  p.  46.    Altorfi,  1713. 


584 

Indeed,  in  the  earliest  stage,  the  greenish  reflection,  which  we  de- 
signate by  the  name  of  glaucoma,  appears  to  come  from  the  very 
bottom  of  the  eye.  As  the  disease  advances,  the  apparent  opacity 
always  of  a  greenish  colour,  and  often  sea-green,  is  seen  as  if  oc- 
cupying the  centre  of  the  vitreous  humour,  and  at  last  appears  to 
be  immediately  behind  the  lens. 

Pathological  Anatomy.  It  is  remarkable  how  very  few  and 
imperfect  are  the  accounts  of  the  dissections  of  glaucomatous  eyes, 
which  have  been  recorded  either  before  or  after  the  tin)e  of  Bris- 
seau.  The  reader  will  at  once  perceive  how  little  could  properly 
be  concluded  from  the  dissection  of  Bourdelot's  eyes  by  Marechal. 
A  single  instance,  however  striking  it  might  be,  and, well  authen- 
ticated, could  not  warrant  a  general  conclusion.  It  is  not  ev^en 
stated,  however,  that  Bourdelot's  eyes  had  ever  presented,  at  any 
period  of  his  life,  the  symptoms  of  glaucoma  ;  so  that  had  not  Bris- 
seau  been  led  by  arguments  of  another  sort.it  is  very  unlikely  that 
he  would  have  drawn  any  thing  from  a  fact  so  insulated  and  in- 
complete. 

Beer  is  mentioned*  as  having  ascertained,  by  dissection,  that  the 
greatest  degree  of  opacity,  in  glaucoma,  resides  in  that  part  of  the 
vitreous  humour,  which  hes  close  to  the  foramen  centrale  of  the 
retina  ;  but,  as  far  as  I  know.  Beer  published  no  account  of  any 
glaucomatous  eyes  which  he  had  dissected  ;  he  says  nothing  of 
such  dissections  in  h.\=,  Leitfaden  ;  and  the  notices  of  his  labours 
on  this  subject,  which  have  been  given  by  others,  are  too  vague  to 
afford  a  basis  for  any  conclusions. 

I  had  long  felt  anxious  to  ascertain,  by  dissection,  the  changes 
which  the  eye  undergoes  in  glaucoma,  and  being  favoured,  some 
time  ago,  with  several  eyes  in  this  state,  I  carefully  examined  them. 
They  were  all  of  them  taken  from  subjects  pretty  far  advanced  in 
hfe.     The  following  are  the  particulars  which  I  observed. 

1.  The  choroid  coat,  and  especially  the  portion  of  it  in  contact 
with  the  retina,  of  a  light  brown  colour,  without  any  appearance 
of  pigmentum  nigrum. 

2.  The  vitreous  humour  in  a  fluid  state  ;  perfectly  pellucid ; 
colourless,  or  slightly  yellow.     No  trace  of  hyaloid  membrane. 

3.  The  lens  of  a  yellow  or  amber  colour,  especially  towards  its 
centre  ;  its  consistence  firm  ;  and  its  transparency  perfect,  or  near- 
ly so. 

4.  In  the  retina,  no  trace  of  Umbus  luteus,  or  foramen  centrale. 

To  the  first  of  these  changes,  namely,  the  deficiency  of  pigmen- 
tum nigrum,  I  am  inclined  to  ascribe,  in  a  great  measure,  the 
opaque  appearance  of  the  deep-seated  parts  of  the  eye  in  glaucoma. 
This  appearance  I  regard  as  a  reflection  merely  of  the  light  from 
the  retina,  choroid,  and  sclerotica  :  it  is  probably  bluish  when  it 
first  leaves  the  reflecting  surface  formed  by  these  membranes,  but 

*  Benedict  de  Morbis  Humoris  Vitrei,  p.  14.     Lipsiae,  1809. 


585 

immediately  assumes  a  greenish  hue  from  passing  through  the 
yellowish  fluid  which  occupies  the  place  of  the  vitreous  humour, 
and  tliiough  the  lens,  which  is  still  more  decidedly  of  a  yellow,  or 
even  amber  colour,  at  that  period  of  life  when  glaucoma  is  most 
apt  to  attack  the  eye. 

Scarpa  has  adopted  a  similar  view  of  the  nature  of  glaucoma, 
namely,  that  it  is  a  reflection ;  but  he  assumes,  seemingly  with- 
out proof,  that  it  is  from  a  thickened  retina  that  the  reflection  takes 
place.  After  mentioning  that  those  cases  of  amaurosis  may  be  re- 
garded as  incurable,  in  which  the  bottom  of  the  eye  presents  an 
unusual  paleness,  similar  to  horn,  sometimes  inclining  to  green,  and 
reflected  from  the  retina  as  if  from  a  mirror,  he  adds,  in  a  note,  the 
following  remarks.  "  The  retina  of  a  sound  eye  is  transparent ; 
and,  therefore,  in  whatever  degree  of  dilatation  the  pupil  may  be, 
the  bottom  of  the  eye  is  of  a  deep  black.  That  unusual  paleness, 
then,  which  accompanies  amaurosis,  indicates  that  a  remarkable 
change  has  happened  in  the  substance  of  the  optic  nerve  forming 
the  retina,  which,  according  to  all  appearance,  is  become  thickened, 
and  rendered  permanently  incapable  of  transmitting  the  impres- 
sions of  light."  * 

I  observe,  also,  that  Mr.  Watson,  of  Edinburgh,  attributes  glau- 
coma to  an  "  opaque  state  of  the  vitreous  humour,  the  retina,  or 
both."  t 

I  have  only  to  say,  that,  in  my  dissections  of  glaucomatous  eyes, 
I  have  detected  no  other  change  in  the  retina  than  what  I  have 
already  mentioned  ;  namely,  a  want  of  the  limbus  luteus  and  fora- 
men centrale.  The  membrane  never  appeared  to  be  thickened  or 
changed  in  colour ;  and  as  for  the  vitreous  humour,  instead  of  be- 
ing thickened  or  opaque,  as  described  by  authors,!  it  was  always 
fluid  and  perfectly  transparent.  I  by  no  means  presume  to  assert 
that  a  turbid  state  of  the  vitreous  fluid,  or  an  opacity  of  the  hya- 
loid membrane  never  occurs  ;  nor  do  I  deny  that  the  retina,  in  cer- 
tain cases,  becomes  thickened  and  opaque.  What  I  believe  myself 
warranted  in  maintaining  is  this,  that  the  well-known  appearances 
of  glaucoma  are  independent  of  any  of  these  changes,  and  to  be 
attributed  to  certain  other  morbid  alterations  of  the  internal  parts 
of  the  eye. 

The  changes  which  the  colour  of  the  choroid  coat  undergoes  at 
different  periods  of  life,  were  carefully  investigated  by  Petit.  He 
tells  us,  that  it  was  the  common  belief  of  anatomists,  that  the  hu- 
man choroid  was  black ;  but  that  even  in  children,  in  whom  it  is 
always  of  a  darker  colour  than  in  adults,  he  had  found  that  portion 
of  it  which  lies  in  contact  with  the  retina,  of  a  deep  brown  only 
(toute-a-fait  hrune)  ;  that  it  is  a  little  less  so  at  the  age  of  twenty 

*  Trattato  delle  principali  Malattie  degli  occhi.     Vol.  ii.  p.  221,  Pavia,  1816. 

t  Compendium  of  the  Diseases  of  the  Human  Eye,  p.  284.     Edinburgh,  1830. 

t  Saepenumero  nimis  spissum,  tenox  et  obscurum  est  hoc  corpus  vitreum,  et  jam 
parit  Glaucoma.  Voit,  Commentatio  exhibens  Oculi  Humani  Anatomian  et  Pathol- 
ogiam,  p.  40.     Norimbergje,  1810. 

74 


586 


years ;  that  it  begins  about  thirty  to  assume  a  dark  gridelin  colour, 
and  that  as  hfe  advances,  this  colour  becomes  gradually  lighter  and 
ligiiter,  so  that  at  eighty  the  choroid  is  almost  white/ 

It  is  not  probable  that  the  light,  reflected  merely  from  a  choroid 
deprived  of  its  pigmentum  nigrum,  and,  in  its  reflexion,  passing 
through  media  perfectly  colourless  and  transparent,  would  produce 
the  greenish  appearance  wdiich  is  so  characteristic  of  glaucoma. 
The  media,  however,  through  which  the  reflected  light  passes, 
before  it  makes  its  exit  from  the  eye,  are  not  colourless.  The  dis- 
solved vitreous  humour  is  generally  somewhat  yellowish,  while 
the  lens,  from  old  age,  is  distinctly  yellow  or  even  amber  coloured. 
Petit  remarks,  that  at  twenty  (he  lens  is  colourless ;  at  thirty,  it 
begins  to  show  a  little  of  a  yellowish  colour ;  at  forty-four  it  is 
straw-coloured  ;  at  fifty-five,  still  more  yellow :  and,  at  seventy  or 
eighty,  resembles  a  bit  of  amber.t  There  is  no  green  surface  iu 
the  human  eye  to  reflect  the  hght  of  that  colour,  as  there  is  in  the 
eye  of  the  sheep ;  it  must  be,  then,  in  its  transmission  that  it  ac- 
quires the  greenish  hue,  and  the  part  most  likely  to  affect  it  in  this 
way  is  the  lens.  Were  it  proved  that  the  retina,  which  is  naturally 
somewhat  bluish,  supported  by  a  choroid  destitute  of  pigment  and 
a  whitish  sclerotica,  reflects  the  light  forward  into  the  eye  of  a 
bluish  colour,  then  one  of  the  principal  phenomena  of  glaucoma 
might  be  regarded  as  no  longer  difficult  of  explanation.  In  con- 
firmation of  this,  if  the  lens  is  removed  in  this  disease,  or  sinks  to 
the  bottom  of  the  dissolved  vitreous  humour,  the  green  appearance 
is  almost  entirely  lost. 

The  dissolved  state  of  the  vitreous  humour,  which  my  dissec- 
tions of  glaucomatous  eyes  lead  me  to  consider  as  an  essential  part 
of  this  disease,  is  always  attended,  at  least  in  what  may  be  called 
the  middle  stage  of  glaucoma,  by  a  preternatural  firmness  of  the 
eye  to  the  touch,  evidently  arising  from  over-distension  of  the  tunics. 
How  far  solution  of  the  vitreous  humour,  or,  in  other  words,  destruc- 
tion of  the  hyaloid  membrane,  and  pressure,  by  a  superabundant 
quantity  of  aqueous  fluid  accumulating  within  the  coats  of  the  eye, 
are  instrumental  in  producing  that  absorption  of  the  pigment  of 
the  choroid  which  attends  glaucoma,  I  shall  not  pretend  absolutely 
to  decide. 

It  is,  I  think,  not  to  be  w^ondered  at,  that  the  destruction  of  the 
hyaloid  membrane  should  be  followed  by  an  accumulation  of  that 
aqueous  fluid,  which  fills  the  space  formerly  occupied  by  the  vitre- 
ous humour.  In  health,  the  hyaloid  membrane  is  undoubtedly 
both  the  secreting  and  absorbing  organ  of  the  vitreous  fluid.  When 
that  membrane  is  destroyed,  the  eye  does  not  shrink  upon  itself. 
A  morbid  secretion,  of  the  origin  of  wdiich  we  can  give  no  accurate 
account,  fills  the  cavity  of  the  retina,  but,  like  other  morbid  pro- 
ductions, is  not  furnished  with  the  apparatus  of  removal,  necessary 

*  Memoires  de  TAcademie  Royale  des  Sciences,  pour  1726.  p.  109.  Amsterdam, 
1732.  t  Ibid.  p.  113. 


I 


587 

for  keeping  its  quantity  in  equilibrio.  Hence  the  unnatural  firm- 
ness of  tbe  glaucomatous  eye,  a  symptom  which  often  increases  to 
such  a  degree,  that  the  organ  is  felt  to  be  of  a  stony  hardness. 

It  not  unfrequently  happens,  after  glaucoma  has  continued  for 
some  time,  that  the  lens  becomes  opaque.  1  have  seen  this  occur 
suddenly,  and  in  other  cases  slowly.  As  the  nutrient  vessels  of 
the  posterior  hemisphere  of  the  capsule  are  derived  from  the  arteria 
centrahs  humoris  vitrei,  it  is  not  surprising  that  the  destruction  of 
the  hyaloid  membrane  should  be  followed  by  opacity  of  the  lens. 
If  an  attempt  be  made  to  operate  on.  such  a  cataract  with  the 
needle,  it  is  apt  to  sink  unexpectedly  to  the  bottom  of  the  vitreous 
humour  ;  if  by  extraction,  the  same  event  sometimes  takes  place, 
so  as  to  frustrate  the  object  of  the  operation,  and  the  eye  is  drained 
by  the  loss  of  dissolved  vitreous  humour.  Even  when  extraction 
is  conducted  with  great  caution,  or  performed,  perhaps,  through  a 
small  section  of  the  cornea,  a  large  quantity  of  this  fluid  is  apt  to 
be  evacuated. 

The  opaque  lens,  left  to  itself,  may  remain  for  many  years  in 
situ,  notwithstanding  the  dissolved  state  of  the  vitreous  humour, 
the  zona  ciliaris  still  preserving  its  adhesion  to  the  cihary  processes  ; 
at  length,  however,  this  adhesion  may  be  destroyed,  when  the 
opaque  lens  will  suddenly  sink  to  the  bottom  of  the  eye,  as  in  the 
case  quoted  from  Mayerne,  at  page  542. 

Symptoms.  Limited  and  sluggish  motion  of  the  pupil,  with 
other  amaurotic  symptoms,  always  attends  glaucoma.  Ultimately 
the  pupil  is  dilated,  and  the  retina  becomes  insensible  to  hght. 
The  loss  of  sight,  however,  is  generally  very  gradual,  and  some- 
times attended,  at  least  for  a  time,  by  a  diminution  in  the  size  of 
the  pupil.  The  want  of  pigmentum  nigrum  may  sufficiently  ex- 
plain tho  weakness  of  sight,  which  accompanies  glaucoma  in  the 
early  stages ;  the  pressure  of  the  accumulated  fluid  within  the  eye, 
is  probably  the  cause  of  the  total  blindness  which  results  at  last. 

If  the  pupil  of  a  glaucomatous  eye  is  small,  the  appearances  are 
apt  to  impose  on  the  inexperienced  observer  for  those  of  cataract. 
The  colour,  however,  of  the  glaucomatous  eye,  is  sufficient  to  prove 
that  the  case  is  at  any  rate  not  one  of  simple  lenticular  cataract, 
for  opacity  of  the  lens  alone  is  never  green.  A  green  cataract  is 
always  attended  with  glaucoma.  On  dilating  the  pupil  by  bella- 
donna, the  green  appearance  presented  in  simple  glaucoma  seems 
to  retire  to  a  greater  depth  behind  the  iris,  and  becomes  more  cir- 
cumscribed. The  other  diagnostic  symptoms  I  have  already  con- 
sidered at  page  475. 

Glaucoma  is  frequently  combined  with  arthritic  inflammation, 
as  has  already  been  stated  at  page  376.  When  this  is  the  case, 
the  sclerotica  and  conjunctiva  become  loaded  with  varicose  vessels 
of  a  livid  colour,  the  pupil  dilates  irregularly,  the  lens  becomes 
opaque,  and  is  pushed  forward  so  as  almost  to  touch  the  ^;  ;rnea ; 
the  junction  of  the  sclerotica  and  cornea  becomes  of  a  pearly-white 


588 

colour  ;  racking  pain  is  complained  of  in  the  eye  and  head,  and 
vision  becomes  totally  extinct.  After  some  time,  the  inflammatory 
symptoms  subside,  and  the  contents  of  the  eyeball  begin  to  be  ab- 
sorbed, so  that  it  shrinks  to  less  than  its  natural  size,  and,  instead 
of  the  preternatural  hardness  which  it  formerly  presented,  becomes 
boggy. 

The  symptoms  which  we  gather  from  the  testimony  of  the  pa- 
tient, are  the  following :  viz.  sensations  of  fiery  and  prismatic 
spectra,  muscee  volitantes,  misty  and  indistinct  vision,  and  pain 
across  the  forehead,  which  is  at  first  slight,  but  often  becomes  se- 
vere. Not  unfrequently  those  who  become  affected  with  glauco- 
ma have  long  suffered  from  those  pains  in  the  teeth  and  head, 
which  are  generally  accounted  rheumatic.  In  some  instances  the 
glaucomatous  eye  is  still  sensible  to  objects  placed  to  one  or  other 
side  of  the  patient,  while  in  every  other  direction  it  distinguishes 
nothing. 

Proximate  Cause.  Inflammation  may,  perhaps,  be  the  cause 
which  leads  to  the  destruction  of  the  hyaloid  membrane  :  and  this, 
in  its  turn,  may  produce  a  series  of  other  local  changes.  It  is 
probable  that  the  aqueous  fluid,  which  fills  the  place  of  the  vitre- 
ous humour,  becoming  superabundant,  promotes,  by  pressure,  the 
absorption  of  pigmentum  nigrum,  and  at  last  renders  the  retina 
insensible. 

Although  it  can  scarcely  be  doubted,  that  the  choroid  exercises 
but  a  subsidiary  part  in  the  production  of  vision,  5"et  it  is  evident, 
that  without  the  aid  of  the  pigmentum  nigrum,  it  is  impossible  for 
a  due  impression  to  be  produced  upon  the  retina.  The  facts,  that 
the  end  of  the  optic  nerve,  where  there  is  no  pigmentum  nigrum, 
is  insensible  to  light,  or  nearly  so,  and  that  the  eye  of  the  Albino, 
congenitaily  destitute  of  pigmentum  nigrum,  is  unable  to  discern 
objects  with  distinctness  in  the  ordinary  light  of  day,  are  sufficient 
to  prove  the  necessity  of  a  healthy  condition  of  the  choroid  for  a  due 
performance  of  the  function  of  vision.  Indeed,  many  physiologists 
have  adopted  the  idea,  that  the  retina,  in  itself,  is  totally  unaffected 
by  light,  being  influenced  only  by  vibrations  communicated  to  it 
by  its  contact  with  the  choroid.  An  argument  lately  advanced  in 
favour  of  this  opinion,  is,  that  in  young  persons,  (generally  below 
the  age  of  twelve),  the  choroid  may  be  observed  to  reflect  a  brilliant 
crimson  colour,  similar  to  what  is  seen  in  the  eyes  of  dogs  and 
other  animals  ;  whence  it  would  follow,  that  if  the  retina  was  af- 
fected by  the  rays  which  fall  upon  it,  these  young  persons  ought 
to  see  the  crimson  light,  reflected  by  the  choroid,  and  striking  upon 
the  retina  in  its  progress  out  of  the  eye,  which,  however,  they  do 
not.* 

Exciting  and  Predisposing  Causes.  The  Germans  appear 
to  consider  glaucoma  as  almost  always  connected  with  arthritis,  or 
rather  as  the  result  of  slow  arthritic  inflammation  of  the  eye. 

♦  Article  Optics,  in  the  Library  of  Useful  Knowledge,  p.  44.     London,  1828. 


589 

Glaucoma  is  much  more  frequently  met  with  in  old  than  in 
young  subjects  ;  rarely  occurring  before  the  age  of  forty  years,  but 
frequently  after  sixty.  Indeed,  so  common  is  glaucoma  in  those 
far  advanced  in  life,  that  we  may  almost  regard  it  as  part  of  the 
changes  coincident  with  old  age. 

I  have  often  been  led  to  suspect  that  the  habitual  use  of  spirits 
and  tobacco  operates  powerfully  in  the  production  of  glaucoma. 
This  disease  also  appears  to  be  more  apt  to  occur  in  those  who  have 
been  scrofulous  in  childhood,  or  who  have  exerted  their  eyes  much 
on  minute  objects.  Yet,  even  taking  these  facts  into  consideration, 
it  is  not  easy  satisfactorily  to  explain  the  frequency  of  glaucoma  in 
some  countries,  and  in  certain  classes  of  society,  and  its  rarity  in 
others.  Thus,  Benedict  tells  us,  that  one  half  of  the  glaucomatous 
patients,  whom  he  had  seen  during  twelve  years'  practice  in  Bres- 
law,  were  Jews,  among  whom  he  states  glaucoma  to  be  extremely 
common.*  Scarpa,  on  the  other  liand,  has  not  thought  it  necessary 
to  introduce  the  subject  of  glaucoma  into  his  treatise  on  the  diseases 
of  the  eye.  It  is  also  remarkable  that,  in  one  of  his  letters  to  Mau- 
noir,  he  mentions,  that  during  the  long  series  of  years  in  which  he 
filled  the  anatomical  chair  at  Pavia,  he  had  never,  in  dissection,  met 
with  dissolution  of  the  vitreous  humour,  and  that  after  reading  Sir 
William  Adams' work,  published  in  1817,  he  made  at  least  forty 
eyes  be  examined,  of  persons  who  had  died  between  sixty  and  eighty 
years  of  age,  without  finding  the  vitreous  humour  either  wholly  or 
partially  dissolved  in  one  of  them.  I  am  certain  that  several  out  of 
any  forty  persons,  above  sixty,  in  this  part  of  the  country,  would  be 
found  glaucomatous,  with  the  vitreous  humour  fluid,  and  the  pig- 
mentum  nigrum  gone. 

Prog7iosis.  When  glaucoma  has  commenced  in  one  eye,  it 
generally  extends  also  to  the  other.  We  often  see  the  disease  in 
different  stages  in  the  two  eyes. 

In  its  fully  formed  stage,  glaucoma  is  absolutely  incurable  ;  but 
it  may  often  be  checked  in  its  progress  ;  and  when  only  one  eye  is 
yet  affected,  it  may  sometimes  be  prevented  from  extending  to  the 
other.  We  cannot  restore  the  secretion  of  pigmentum  nigrum,  but 
remedies  may  occasionally  arrest  the  disease,  and  even  improve  the 
impaired  vision. 

Treatment.  1.  On  the  presumption  that  glaucoma  originates  in 
an  inflammatory  affection  of  the  hyaloid  membrane,  bleeding  and 
purging  have  been  employed  in  order  to  arrest  its  progress  ;  and 
occasionally  this  practice  has  been  attended  with  benefit.  Counter- 
irritation,  also,  has  been  found  useful,  and  especially  the  tartar  emet- 
ic eruption  between  the  shoulders. 

2.  Calomel,  with  opium,  has  been  given,  on  the  principle  that  in 
almost  all  cases  of  deep-seated  inflammation  of  the  eye,  mercury 

*  Handbuch  der  praktischen  Augenheilkunde.     Vol.  v.  146.  Leipzig,  1825. 


590 

proves  salutary.  As  is  the  case  in  arthritic  ophthalmia,  with  which 
glaucoma  is  certainly  allied,  an  alterative  course  will  prove  more 
beneficial  than  if  the  mercury  were  pushed  so  as  severely  to  affect 
the  mouth.  Indeed,  it  is  evident  that  from  the  age  and  constitution 
of  those  who  are  in  general  the  subjects  of  glaucoma,  neither  deple- 
tion nor  mercurialization  can,  with  propriety,  be  employed,  without 
more  than  ordinary  caution. 

3.  Rest  of  the  eyes,  a  mild  diet,  a  healthy  state  of  the  skin,  and 
abstinence  from  alcoholic  fluids,  and  tobacco,  in  every  form,  must  be 
enjoined. 

4.  Arthritic  inflammation  of  the  eye  is  often  greatly  benefitted  by 
the  use  of  tonics  ;  as  precipitated  carbonate  of  iron,  sulphate  of  qui- 
na,  and  the  like.  After  depletion,  such  remedies  may  be  also  tried 
in  glaucoma. 

5.  Dilatation  of  the  pupil  by  belladonna  greatly  improves  the 
vision  of  most  glaucomatous  eyes,  and  may  be  employed  day  after 
day  as  a  paUiative.  The  most  convenient  mode  of  applying  the 
belladonna  is  in  aqueous  solution,  filtered  through  paper,  and  drop- 
ped upon  the  conjunctive  morning  and  evening. 

6.  As  a  superabundance  of  dissolved  vitreous  humour  appears  to 
form  an  essential  part  of  the  morbid  changes  which  take  place  in 
the  glaucomatous  eye,  it  is  not  unreasonable  to  conclude  that  occa- 
sionally puncturing  the  sclerotica  and  choroid  might  prove  service- 
able, by  reheving  the  pressure  of  the  accumulated  fluid  on  the  retina. 
The  puncture  should  be  made  with  a  broad  iris-knife,  at  the  usual 
place  of  entering  the  needle  in  the  operation  of  couching.  The  in- 
strument should  be  pushed  towards  the  centreof  the  vitreous  humour, 
turned  a  httle  on  its  axis,  and  held  for  a  minute  or  two  in  the  same 
position,  so  that  the  fluid  may  be  allowed  to  escape. 

7.  The  removal  of  the  crystalline  lens  from  a  glaucomatous  eye 
not  only  lessens  very  much  the  greenish  appearance  of  the  humours, 
but  improves  the  vision  of  the  patient.  At  the  same  time,  although 
I  am  persuaded  that  the  absence  of  the  lens  might  be  advantageous 
even  in  the  early  stage  of  this  disease,  and  prevent,  in  a  considera- 
ble measure,  its  further  progress,  extraction  is  an  operation,  which 
I  would,  by  no  means,  venture  to  recommend  for  general  adoption 
in  such  cases.  The  patient  generall}^  sees  too  much  to  warrant  our 
exposing  him  to  the  danger  of  arthritic  inflammation  coming  on  af- 
ter the  operation.  I  have  known  glaucoma  operated  on  for  cataract ; 
that  is  to  say,  the  amber-coloured  lens  removed  by  extraction,  the 
operator  apprehending  that  he  was  removing  an  opaque  or  cataract- 
ous  lens  ;  and  I  have  seen  the  incision,  after  such  an  operation,  heal 
without  inflammation,  and  the  patient  receive  a  considerable  acces- 
sion of  vision.  But  I  have  also  known  such  violent  inflammation 
follow  the  removal  of  the  lens  from  a  glaucomatous  eye,  as  entirely 
destroyed  the  natural  structure  of  the  most  important  parts  of  the 
organ. 


591 

That  the  early  removal  of  the  lens  might  prove  a  means  of  pre- 
venting glaucoma,  is  a  conclusion  to  which  I  was  naturally  led  by 
the  following  case. 

R.  C.  aged  48  years,  applied  to  me  in  March,  1820,  in  conse- 
quence of  impaired  vision  of  the  left  eye,  which  already  presented 
a  glaucomatous  appearance.  In  his  right  eye,  there  was  a  capsu- 
lar cataract,  the  result  of  an  injury  forty  years  before,  which  had 
been  followed  by  absorption  of  the  crystalline  lens.  The  vision  of 
the  left  eye  rapidly  dechning,  while  evident  perception  of  light  and 
shadow  was  still  retained  b)^  the  right,  I  opened  the  cornea  of  this 
eye,  and  drew  the  capsule  out  of  the  pupil,  and  partially  between 
the  lips  of  the  incision  of  the  cornea,  leaving  it  to  adhere  there,  and 
thus  securing  a  passage  for  the  rays  of  light  into  the  anterior  of  the 
eye.  As  good  vision  was  restored  by  this  means  as  generally  fol- 
lows an  operation  for  cataract,  and  the  patient  is  still  able,  wnth  the 
assistance  of  the  right  eye  and  a  cataract-glass,  to  follo\v  his  usual 
employment.  The  vision  of  the  left  eye  became  still  more  impaired, 
under  signs  which  appeared  to  me  indubitably  those  of  glaucoma 
and  amaurosis.  The  patient,  however,  was  persuaded  that  he  had 
a  cataract  in  this  eye,  and  urged  me  to  operate  on  it.  This  I  de- 
clined ;  but  I  recommended  the  patient,  since  he  still  had  doubts 
about  the  matter,  to  consult  the  late  Dr.  Monteath.  He  did  so,  and 
felt  greatly  disappointed  when  Dr.  M.  only  confirmed  the  opinion 
which  I  had  previously  given  him.  Not  yet  satisfied,  he  went  to 
Edinburgh,  where  he  unfortunately  met  with  encouragement  in 
the  notion  of  his  eye  being  affected  with  cataract,  and  accordingly 
underwent  an  operation,  which  was  only  followed  by  violent  and 
destructive  inflammation. 

Now,  it  has  always  struck  me  in  reflecting  on  this  case,  that  the 
total  absence  of  glaucoma  in  the  right  eye  might  have  been  owing 
to  the  lens  having  been  absorbed  at  an  early  period  of  life  ;  for 
glaucoma  is  a  disease,  which,  under  ordinary  circumstances,  very 
rarely,  if  ever,  attacks  the  one  eye  without  speedily  affecting  the 
other  also.  The  absence  of  the  lens  may  have  operated  in  prevent- 
ing the  affection  of  the  hyaloid  membrane,  which  ends  in  its  de- 
struction, and  to  which  I  feel  inclined,  so  far  as  our  present  evidence 
goes,  to  attribute  that  series  of  changes,  which  gives  rise  to  the 
symptoms  of  glaucoma. 


SECTION  II. CATS-EYE. 

This  disease  derives  its  name  from  the  opalescent  appearance  of 
the  pupil,  which  reflects  the  hght  in  various  colours,  or  at  least  with 
various  degrees  of  intensity,  according  to  the  direction  in  which 
the  eye  is  turned,  resembling,  in  this  respect,  a  piece  of  opal,  or  the 
mineral  called  cats-eye.     This  appearance  is  so  remarkable,  that 

*  Das  amaurotischcs  Katzenauge  of  Beer. 


592 

when  the  disease  is  fully  developed,  it  is  impossible  to  mistake  it. 
Beer  has  compared  it  to  the  reflection  from  the  eye  of  a  cat  in  the 
dark,  and  hence  the  name  which  he  has  bestowed  on  this  disease. 
Tlie  comparison,  however,  to  the  mineral  cats-eye,  is  much  more 
just. 

Beer  describes  the  pecuUar  reflection  of  the  light,  w^iich  takes  place 
in  this  disease,  as  if  coming-  in  the  early  stage  from  the  bottom  of  the 
eye,  and  apparently  from  a  concave  surface,  and  presenting  a  lead- 
en-grey, whitish -yellow,  or  reddish  and  changeable  colour.  When 
fully  developed,  one  may  perceive,  he  says,  on  careful  examination, 
a  fine  netw^ork  of  blood-vessels  spread  over  the  bottom  of  the  eye, 
which  no  doubt  are  the  branches  of  the  arteria  centralis  retinee. 
The  iris  is  also  observed,  as  the  disease  advances,  to  become  pale 
and  semi-transparent.  The  pupil  loses  its  pow-er  of  motion,  re- 
maining fixed  in  the  middle  state  between  contraction  and  dilata- 
tion. Vision  is  greatly  impaired,  although  seldom,  if  ever,  altogether 
lost. 

This  rare  disease  is  more  frequently  met  with  in  old  people  in- 
clined to  general  marasmus,  than  in  any  other  individuals.  Occa- 
sionally, however,  it  occurs  in  atrophic  children. 

In  the  few  cases  of  this  disease  which  have  come  under  my  ob- 
servation, I  could  discover  nothing  of  the  appearances  W'hich  Beer 
has  described  as  arising  from  the  bottom  of  the  eye.  The  reflected 
and  varpng  light  seemed  to  me  to  come  from  the  front  of  the  crys- 
talline capsule.  Viewing  the  eye  directly  in  front,  the  appearance 
has  been  that  merely  of  a  brownish  opacity  ;  but  w^henever  the  pa- 
tient looked  upwards,  the  opalescence  became  very  striking,  present- 
ing almost  a  glittering  or  silvery  reflection. 

The  nature  of  this  disease  has  never  been  determined  by  dissec- 
tion. The  paleness,  which  the  iris  assumes,  naturally  leads  to  the 
supposition  that  there  is  a  deficiency  of  pigmentum  nigrum  ;  but 
this  is  probably  only  part  of  the  morbid  changes. 

A  tonic  plan  of  treatment  appears  the  most  likely  to  check  the 
progress  of  this  complaint,  especially  in  children. 

In  one  case,  in  wdiich  both  eyes  were  affected,  and  a  mere  per- 
ception of  light  and  shadow^  was  retained,  I  ventured,  at  the  pa- 
tient's request,  to  open  one  of  the  corneee,  and  introduce  a  cataract 
needle  through  the  pupil.  I  felt  nothing  like  the  resistance  of  the 
lens,  a  profuse  discharge  of  aqueous  fluid  took  place,  the  cornea 
healed,  and  the  opalescent  appearance  continued  almost  exactly  the 
same  as  before  tlie  operation.  I  am,  therefore,  led  to  regard  cats-eye 
as  a  variety  of  glaucoma,  and  I  suspect  that,  on  dissection,  the  eye 
will  be  found  deficient  in  crystalline  lens  as  well  as  in  pigmentum 
nigrum. 


598 
CHAPTER  XVIII. 

VARIOUS  STATES  OF  DEFECTIVE  VISION. 

SECTION  I. MYOPIA,*  OR  NEAR-SIGHTEDNESS. 

There  is  a  certain  distance  from  the  eye,  called  the  point  of  dis- 
tinct vision,  at  which  objects  are  perceived  better  than  at  any  other 
distance.  This  point,  however,  is  different  in  different  individuals, 
or  even  in  the  two  eyes  of  the  same  person.  It  averages  from 
about  15  to  20  inches.  The  least  distance  at  which  objects  can 
be  seen  with  any  ordinary  degree  of  distinctness  by  common  eyes, 
is  about  seven  or  eight  inches.  But  there  is  a  certain  class  of  eyes, 
namely,  the  myopic,  which  can  discern  no  object  distinctly  unless 
it  be  brought  nearer  than  the  ordinary  distance  for  distinct  vision, 
or  even  within  the  distance  of  seven  inches  ;  while  there  is  another 
class,  namely,  the  pre^'fe^/op^c,  which  require  the  object  to  be  re- 
moved farther  away  than  the  average  point  of  distinct  vision. 

These  two  classes  of  defective  eyes  are  generally  regarded  as 
dependent  upon  some  peculiarity  in  the  transparent  media  of  the 
organ.  In  the  myopic  eye  it  is  supposed  that  the  rays  of  light 
must  either  be  refracted  too  much,  so  that  they  converge  into  foci 
anteriorly  to  the  retina,  or  that  the  axis  of  the  eye  must  be  longer 
than  natural,  so  that  the  retina  is  too  far  back,  and  does  not  re- 
ceive that  perfect  impression  which  is  necessary  for  distinct  vision. 
The  reverse  of  this  is  supposed  to  have  place  in  the  presbyopic  eye. 
Either  its  axis  is  too  short,  or  its  refractive  powers  too  feeble,  so 
that  the  rays  of  light  proceeding  from  objects  and  entering  the  eye, 
tend  to  collect  into  foci,  not  upon  the  retina  as  they  ought  to  do, 
but  behind  it.  It  is  only,  however,  by  that  degree  of  refraction,  or 
with  that  form  of  the  eye,  which  permits  the  rays  of  light,  pro- 
ceeding from  the  luminous  points  of  objects,  to  be  brought  into 
corresponding  or  nearly  corresponding  focal  points  upon  the  retina, 
that  distinct  vision  can  be  produced.  Falhng  either  before  the 
retina,  or  tending  to  fall  behind  it,  the  image  will  necessarily  be 
diluted,  and  the  impression  imperfect.  To  remedy  these  defects, 
the  person  affected  with  myopia  brings  the  object  within  that  dis- 
tance, which  will  ensure  the  image  being  thrown  so  far  back  as  to 
fall  upon  the  retina,  while  the  presbyopic  person,  by  removing  the 
object  to  a  certain  distance  from  his  eye,  brings  the  image  forwards 
to  the  same  point. 

Synipto7ns  of  Myopia.  As  the  myopic  eye  has  its  point  of 
distinct  vision  as  well  as  the  sound  one,  those  affected  with  the 
greatest  degree  of  near-sightedness  bring  every  object,  which  they 

*  From  IJ.UU),  to  shut,  and  a>^,  the  eye ;  the  (xvai^  or  short-sighted  person  being 
in  the  habit  of  winking  or  half-shutting  his  lids,  when  he  endeavours  to  see  objects 
distinctly. 

75 


594 

Avish  to  see  clearly  and  distinctly,  to  the  distance  of  two  or  three 
inches,  or  even  as  close  as  one  inch  from  the  eye,  while  other  my- 
opic persons  are  able  to  enjo)'^  as  good  \asion  although  the  object  is 
at  six  or  nine  inches'  distance.  The  eye  which  perceives  noth- 
ing distinctly  beyond  ten  inches  may  be  considered  myopic.  This 
imperfection,  then,  cannot  be  concealed,  if  the  individual  affected 
with  it  attempts  to  read,  or  to  examine  any  small  object  minutely. 
If  we  direct  his  attention  to  objects  at  any  considerable  distance,  it 
is  evident  that  tbey  either  make  no  impression  on  his  retina,  or 
one  which  is  exceedingly  indefinite  and  obscure.  He  cannot  dis- 
tinguish the  countenances  of  the  performers  on  the  stage,  nor  the 
subject  of  pictures  when  placed  a  few  feet  above  his  head ;  he 
cannot  read  the  inscriptions  on  doors  and  houses,  nor  recognise 
persons  across  the  street ;  if  he  go  into  a  large  room,  in  which  there 
are  many  persons,  he  cannot  readily  distinguish  those  he  knows. 

It  is  remarked  of  those  who  are  short-sighted,  that  they  do  not 
look  at  the  person  with  whom  they  converse,  because  they  cannot 
see  the  motion  of  his  eyes  and  features,  and  therefore  they  are  at- 
tentive to  his  words  only  ;  that  in  reading,  they  hold  the  book  ob- 
liquely towards  their  eyes,  this  helping  them  to  see  it  distinctly, 
either  by  allowing  the  light  to  illuminate  it  better,  or  by  bringing 
its  image  upon  the  lateral  part  of  the  retina ;  that  they  see  more 
distinctly  and  somewhat  farther  off  by  a  strong  light  than  a  weak 
one,  on  account  of  the  contraction  of  the  pupil  which  is  thereby 
produced,  and  which  serves  to  exclude  all  but  the  more  direct  rays 
of  light,  and  consequently  to  lessen  the  apparent  confusion  ;  that 
on  the  same  principle,  when  they  endeavour  to  see  any  distant  ob- 
ject distinctly,  they  almost  close  their  eyelids,  and  that  through  a 
pin-hole  in  a  card,  objects  appear  to  them  much  clearer  and  better 
defined. 

Short-sighted  persons  write  a  small  hand,  and  prefer  to  read  a 
small  type,  because  they  can  thus  see  more  at  a  view.  They  can 
read  a  very  small  print,  in  a  degree  of  light  quite  insufficient  to 
allow  an  ordinary  eye  to  make  out  even  large  letters.  When  they 
endeavour  to  write  in  a  large  hand,  they  find  it  difficult  to  do  so, 
and  are^apt  to  mis-shape  the  letters. 

The  eyes  of  those  who  are  short-sighted  are  frequently  promi- 
nent ;  the  cornea  is  sometimes  preternaturall}^  convex,  the  pupil 
generally  large,  the  eyeball  firm,  the  eyelids  often  tender. 

It  is  a  question  which  naturally  occurs  to  one  who  first  turns  his 
attention  to  the  nature  of  myopia,  whether  this  disease  consists 
merely  in  over-refraction,  or  involves  also  a  deficiency  in  the  ac- 
commodating power  of  the  eye  to  different  distances.  Dr.  Smith, 
no  mean  authority  on  such  a  subject,  is  decidedly  of  opinion,  that 
the  power  of  varying  the  quantity  of  refraction  is  still  retained  by 
the  myopic  eye.  "If  short-sighted  persons,"  says  he,  "can  read  a 
small  print  distinctly  at  two  different  distances,  whereof  the  larger 
is  but  double  the  lesser,  which  I  beUeve  most  of  them  can  do ;  it 


595 

follows  that  as  great  alterations  of  figures  are  made  in  their  eyes 
as  in  perfect  eyes,  that  can  see  distinctly  at  all  intermediate  dis- 
tances between  infinity  and  the  larger  of  these  two.  And  this  is 
the  reason  that  a  short-sighted  person  can  see  distinctly  at  all  dis- 
tances with  one  single  concave  of  a  proper  figure  ;  which  other- 
wise must  have  been  differently  figured  for  different  distances.  It 
follows  then  that  the  cause  of  short-sightedness,  is  not  a  want  of 
power  to  vary  the  figure  of  the  eye,  and  the  quantity  of  refraction  ; 
but  that  this  whole  quantity  is  always  too  great  for  the  distance  of 
the  retina  from  the  cornea."  * 

It  is  rarely  the  case  that  the  two  eyes  even  of  the  same  person 
correspond  in  refractive  power.  The  left,  partaking  perhaps  in  the 
tendency  to  debility  and  disease,  which  so  frequently  attaches  itself 
to  the  left  side  of  the  body,  is  often  found  to  be  somewhat  short- 
sighted. Few  are  aware  of  the  disparity  which  often  exists  be- 
tween their  eyes,  until  some  accidental  circumstance  leads  them 
to  make  a  comparative  trial  of  the  two ;  and  it  is  by  no  means  un- 
common to  meet  with  individuals,  who,  on  making  the  experiment,, 
have  discovered  that  one  eye  was  greatly  defective,  or  even  entirely 
bhnd. 

Mr.  Wardrop  remarks  t  that  it  will  generally  be  found,  that  not 
only  the  right  is  more  perfect  than  the  left  eye,  but  that  when  a 
person  is  apparently  looking  at  an  object  with  both  eyes,  generally 
only  one  of  them,  and  that  the  right  one,  is  actually  directed  to  the 
object.  But  this  will  depend  entirely  on  whether  the  right  or  the 
left  is  the  better  of  the  two.  To  ascertain  the  fact,  let  a  spot,  at 
the  distance  of  a  few  yards  from  the  observer,  be  covered  with  the 
point  of  one  of  his  fingers,  while  he  endeavours  to  look  at  it  with 
both  eyes.  If  the  short-sighted  eye,  which  we  may  suppose  to  be 
the  left,  be  now  closed,  the  point  of  the  finger  will  continue  to  ap- 
pear to  cover  the  spot,  and  to  preserve  the  same  relative  situation 
to  it  as  when  both  eyes  were  open  ;  but  if  the  right  eye  be  closed 
and  the  left  opened,  then  the  relative  situation  of  the  point  of  the 
finger  and  spot  will  appear  altered,  the  spot  being  uncovered ; 
proving,  that  in  directing  the  finger  to  cover  the  spot,  the  right  eye 
had  alone  been  employed.  Mr.  Wardrop  has  met  with  myopia 
more  frequently  in  the  left  eye  than  the  right;  Mr.  Ware,  on  the 
other  hand,  observes  that  most  of  the  near-sighted  persons  with 
whom  he  has  conversed,  had  the  right  more  affected  than  the  left, 
and  he  thinks  it  not  improbable  that  the  differences  had  arisen  from 
the  habit  of  using  a  single  concave  hand-glass,^  which,  being  com- 
monly applied  to  the  right  eye,  contributes  to  render,  it  more  short- 
sighted than  the  other.l 

Although  near-sightedness  is  in  general  gradual  in  its  progress, 
manifesting  itself  about  the  period  of  puberty,  and  increasing  from 

*  Complete  System  of  Optics.     Vol.  ii.  p.  2.     Cambridge,  1738. 

t  Morbid  Anatomy  of  the  Human  Eye.    Vol.ii.  p.  229.     London,   1818. 

t  Philosophical  Transactions.     Vol.  ciii.  p.  34.     London,  1813. 


596 

that  period  up  to  twenty  or  twenty -five  years  of  age,  yet  in- 
stances occasionally  occur  of  its  existence  even  in  children,  or  of 
its  suddenly  affecting  the  eye  of  a  grown-up  person,  who  had  pre- 
viously seen  distinctly  at  the  ordinary  distance.  In  the  cases  of 
children,  we  should  examine  the  appearances  presented  through  the 
pupil,»for  very  often  a  central  cataract*  will  be  found  to  exist  under 
such  circumstances  ;  w^iile  the  sudden  accession  of  myopia  in  those 
who  had  previously  seen  well,  should  lead  us  to  suspect  either 
dropsy  of  the  vitreous  humour  t  or  some  affection  of  the  brain. 

Efficient  Causes.  Myopia  has  been  attributed  to  a  variety  of 
efficient  causes,  several  of  which  may  coexist. 

1.  Too  great  convexity  of  the  Cornea.  As  it  is  before  the 
rays  of  hght  reach  the  crystalline  lens  that  they  undergo  their 
gi'eatest  degree  of  refraction,  it  is  evident  that  a  preternatijrally  con- 
vex cornea  will  produce  a  convergence  so  rapid,  that  the  foci  will 
fall  very  considerably  short  of  the  retina.  While  it  is  undeniable, 
however,  that  in  some  of  the  very  aggravated  instances  of  myopia, 
the  cornea,  natural  in  diameter,  may  be  observed  to  project  consid- 
erably above  its  average  altitude,  it  is  also  certain  that  this  con- 
formation is  by  no  means  a  common,  nor  even  a  frequent,  attend- 
ant on  this  disease.  When  it  does  occur,  it  is  generally  accom- 
panied by  a  superabundant  quantity  of  aqueous  humour,  and  occa- 
sionally by  a  degree  of  pressure  backwards  on  the  iris,  so  that  this 
membrane,  instead  of  being  plane  or  convex,  becomes  concave  on 
its  anterior  surface. 

2.  Too  great  thickness  of  the  cornea  will  undoubtedly  tend 
to  bring  the  rays  of  light  to  a  focus  sooner  than  they  ought  to  be 
brought ;  but  it  is  not  at  all  likely  that  the  cornea  is  ever  of  such 
extraordinary  thickness  in  the  adult  eye,  as  of  itself  to  be  the 
cause  of  myopia,  unless  at  the  same  time  it  projects  in  a  conical 
form.t  At  birth,  indeed,  the  cornea  is  very  thick  in  proportion  to 
the  size  of  the  eye";  and  to  this  Petit  has  ascribed  (in  part)  the 
indistinctness  of  vision  in  very  young  children. § 

3.  Too  great  convexity  of  the  crystalline  lens  wiU  assuredly 
produce  short-sightedness,  whether  the  over-convexity  be  on  one 
only,  or  on  both  sides  of  that  body.  Such  conformation  has  been 
regarded  as  probably  one  of  the  most  frequent  causes  of  myopia  ; 
and  notwithstanding  the  testimony  of  Percy  and  Reveille-Parise,|| 
that  on  examining  the  lenses  taken  from  the  eyes  of  a  number  of 
persons  who  during  life  had  been  short-sighted,  they  were  unable  to 
detect  any  excessive  convexity,  we  must  still  admit  not  merely 
the  possibility  of  this  cause,  but  the  likelihood  of  its  frequent  ex- 
istence. 

4.  Preternatural  density  of  any  or  all  of  the  transparent 
media  of  the  eye  is  also  a  cause,  which   will  infallibly  produce 

*  See  page  483;  t  See  page  444.  t  See  page  437. 

§  Memoires  de  I'Academie  Royale  des  Sciences,  pour  1727;  p.  346.  Amsterdam, 
1732.  II  Hygiene  Oculaire,  par  J.  H.  Reveille-Parise ;  p.  32.     Paris,  1816. 


1 


597 

myopia,  and  which  is  not  unUkely  to  occur,  I  have  generally 
observed  that  myopic  eyes  are  considerably  firmer  tO'  the  touch 
than  natural,  even  at  an  early  period  of  life. 

5.  Preternatural  elongation  of  the  eyeball.,  so  that  the  dis- 
tance between  the  cornea  and  retina  is  increased,  will  necessarily 
occasion  myopia,  and  has  even  been  regarded  by  some  as  the  only 
admissible  cause  of  this  disease.  Such  conformation  of  the  eye 
has  been  supposed  to  be  sometimes  congenital,  and  in  other  cases 
to  be  acquired  from  frequent  exercise  of  the  sight  upon  minute  ob- 
jects. 

6.  The  dilated  state  of  the  pupil.,  which  almost  always  ac- 
companies myopia,  has  been  generally  set  down  amongst  the 
causes  of  this  disease,  whereas  it  is  much  more  probably  an  effect. 
When  the  sight  is  perfect,  and  still  more  when  it  is  presbyopic,  the 
pupil  will  have  frequent  occasion  to  contract,  in  aiding  the  person 
to  see  near  objects  more  distinctly,  and  thus  an  habitual  degree 
of  myosis  may  be  produced ;  but  in  those  who  are  short-sighted 
this  will  not  happen,  for  to  them  near  objects  appear  distinct,  and 
therefore  not  having  occasion  to  contract  the  pupil  for  seeing  such 
objects  more  distinctly,  this  aperture  probably  maintains  an  habitual 
state  of  dilatation. 

Subjects  of  myopia.  1.  Age.  Young  people  seldom  discover 
that  they  are  remarkably  near-sighted,  until  about  the  age  of  pu- 
berty, or  when  they  begin  to  use  their  eyes  in  earnest.  Many 
persons  reach  the  age  of  thirty  or  forty  years,  who  have  no  notion 
that  they  are  near-sighted,  until  they  happen  accidentally  to  look 
through  the  concave  glasses  of  some  other  individual,  when  they 
are  surprised  and  delighted  to  find  that  they  perceive  remote  objects 
with  a  clearness  and  sharpness  of  outline,  to  which  they  had  for- 
merly been  altogether  strangers.  They  may  have  suspected  that 
they  did  not  see  across  the  street  or  at  the  theatre,  quite  so  plainly 
as  other  people,  but  as  they  could  read  a  small  print  as  well  as  any 
body,  they  had  no  idea  that  they  were  the  subjects  of  any  defect  in 
their  eyes,  or  that  they  could  improve  their  vision  by  any  kind  of 
glass. 

It  has  been  very  generally  asserted  that  near-sighted  eyes  are 
by  age  rendered  fitter  for  perceiving  distant  objects  than  they  were 
in  youth.  This  opinion  appears  to  have  been  built  on  the  follow- 
ing false  analogy  ;  viz.  That  if  those  who  possess  ordinary  vision 
when  young,  become  from  the  flatness  of  the  cornea  or  other 
changes  in  the  structure  of  the  eye.  far-sighted  as  they  approach 
to  old  age,  which  is  a  well-established  fact,  then,  the  short-sighted 
must,  from  similar  changes,  become  better  fitted  to  see  distant 
objects.  Short-sightedness  tends  generally  to  increase  rather  than 
diminish,  as  age  advances ;  and  should  it  be  joined  by  glaucoma, 
the  person  is  obliged  to  bring  any  object,  which  he  wishes  to 
see  distinctly,  within  a  very  short  distance  of  the  eye.  It  not  un- 
frequently  happens,  however,  that  as  a  near-sighted  person  advances 


598 

in  years,  he  both  becomes  shorter-sighted  so  far  as  the  vision  of  diis* 
tant  objects  is  concerned,  and  longer-sighted  in  respect  to  near  ob- 
jects. He  finds  that  he  can  read  with  tiis  naked  eye,  at  nearly  the 
ordinary  distance,  which  he  could  not  do  before,  or  he  is  obliged 
even  to  use  convex  glasses  in  reading  ;  but  at  the  same  time  he 
finds  himself  under  the  necessity  of  employing  deeper  concave 
glasses  than  ever  for  the  perception  of  distant  objects. 

2.  Rank  and  Occupation.  Myopia  is  much  more  common  in 
the  higher  than  in  the  lower  ranks  of  life,  and  among  those  who 
occupy  themselves  with  the  close  examination  of  minute  objects 
than  in  those  who  scarcely  ever  attempt  to  read,  write,  or  apply 
themselves  to  an}'  similar  pursuit.  Mr.  Ware  remarks,  that  among 
persons  in  the  inferior  stations  of  society,  artificial  means  are  rare- 
ly resorted  to  for  correcting  shght  defects  of  this  nature  ;  and  that 
there  is  even  reason  to  believe,  that  in  such  people,  near-sightedness 
is  not  unfrequently  overcome  by  the  increased  exertions  that  are 
made  by  the  eye  to  distiiiguish  distant  objects.  When  persons  in 
the  higher  ranks,  on  the  other  hand,  discover  that  their  discern- 
ment of  distant  objects  is  less  quick  or  less  correct  than  that  of  others, 
though  the  difference  may  be  very  slight,  influenced  perhaps  by 
fashion  more  than  by  necessity,  they  immediately  have  recourse  to 
a  concave  glass  ;  the  natural  consequence  of  which  is,  that  their 
eyes  in  a  short  time  become  so  confirmedl}^  myopic,  that  the  recov- 
ery of  distant  vision  is  difficult,  if  not  impossible. 

With  regard  to  the  proportion  of  near-sighted  persons  in  the  dif- 
ferent ranks  of  society,  Mr.  W'are  endeavoured  to  obtain  satisfac- 
tory information,  by  making  inquiry  in  those  places  where  a  large 
number  of  individuals  of  nearly  the  same  station  are  associated  to- 
gether. He  inquired  for  instance  of  the  surgeons  of  the  three  regi- 
ments of  foot-guards,  consisting  of  nearly  10,000  men  ;  and  he  was 
informed  that  near-sightedness  v.as  almost  unknown  amongst  them, 
not  six  individuals  having  been  discharged,  nor  six  recruits  rejected, 
on  account  of  this  imperfection,  in  the  space  of  nearly  twenty  years. 
At  the  Military  School  at  Chelsea,  where  tliere  were  1300  children, 
the  complaint  of  near-sightedness  had  never  been  Uiade  among 
them,  until  Mr,  Ware  mentioned  it,  and  then  only  three  were  found 
who  experienced  the  least  inconvenience  from  it.  He  pursued  his 
inquiries  at  several  oi'  the  colleges  in  Oxford  and  Cambridge,  and 
found  near-sightedness  very  prevalent  in  these  institutions.  In  one 
college  in  Oxford,  where  the  society  consisted  of  127  members, 
thirt3'-two  either  wore  spectacles  or  used  hand-glasses.  It  is  not  im- 
probable, that  some  of  these  were  induced  to  do  so  solely  because  the 
practice  was  fashionable  :  but  Mr.  W^are  believes  the  number  of  such 
to  have  been  inconsiderable,  compared  with  that  of  those  whose 
sight  received  some  small  assistance  from  glasses,  although  this  as- 
sistance could  have  been  dispensed  with,  without  inconvenience,  if 
the  practice  had  not  been  introduced.* 

**  Philosophical  Transactions,  Vol.  ciii.  p-  31.    London,  1813. 


I 


599 

Treatment.  It  is  but  rarely  the  case  that  the  medical  prac- 
titioner has  an  opportunity  of  advising  those  in  whom  myopia  is 
not  yet  confirmed,  to  that  course  of  treatment,  which  might  remove 
the  incipient  symptoms  of  this  very  serious  imperfection  of  sight. 
If  it  be  correct,  that  this  disease,  in  by  far  the  greater  number  of 
instances,  is  induced  by  too  much  exercise  of  the  eyes  upon  minute 
objects,  as  in  reading,  writing,  sewing,  miniature  painting,  en- 
graving, and  the  like,  the  cure  would  probably  be  found  in  ab- 
staining entirely  for  a  time  from  such  occupations,  refraining  also 
from  the  use  of  concave  glasses,  and  employing  the  eyes  chiefly 
upon  large  and  distant  objects.  Haller  recommends  looking  through 
a  small  aperture,  as  a  remedy  for  myopia ;  but  probably  this,  as 
well  as  gradually  removing  the  book  from  the  eye,  till  it  can  be 
read  at  the  ordinary  distance ;  reading  through  convex  glasses ; 
and  other  attempts  of  a  similar  sort,  will  prove  of  little  use,  in  com- 
parison of  the  good  effects  to  be  derived  from  frequent  exercise  out 
of  doors,  walking  and  riding  into  the  country,  and  travelling 
through  new  and  interesting  scenes. 

If,  instead  of  such  a  plan  of  treatment,  recourse  be  had  to  the 
employment  of  concave  glasses,  and  the  frequent  and  long-con- 
tinued observation  of  near  objects  be  persisted  in,  the  disease  be- 
comes not  only  confirmed,  but  sometimes  greatly  aggravated. 

"  When  I  first  learned  to  read,  at  the  usual  age  of  four  or  five 
years,"  says  Sir  Charles  Blagden,  "  I  could  see  most  distinctly, 
across  a  wide  church,  the  contents  of  a  table  on  which  the  Lord's 
Prayer,  and  the  Belief,  were  painted  in  suitably  large  letters.  In 
a  few  years,  that  is,  about  the  ninth  or  tenth  of  my  age,  being 
much  addicted  to  books,  I  could  no  longer  read  what  was  painted 
on  this  table  ;  but  the  degree  of  near-sightedness  was  then  so  small, 
that  I  found  a  watch-glass,  though  as  a  meniscus*  it  made  the 
rays  diverge  very  little,  sufficient  to  enable  me  to  read  the  table 
as  before.  In  a  year  or  two  more,  the  watch-glass  would  no  longer 
serve  my  purpose ;  but  being  dissuaded  from  the  use  of  a  common 
concave  glass,  as  likely  to  injure  my  sight,  I  suffered  the  incon- 
venience of  a  small  degree  of  myopy,  till  I  was  more  than  thirty 
years  of  age.  That  inconvenience,  however,  gradually  though 
slowly  increasing  all  the  time,  at  length  became  so  grievous,  that 
at  two  or  three  and  thirty,  I  determined  to  try  a  concave  glass  ; 
and  then  found,  that  the  numbers  two  and  three  were  to  me  in 
the  relation  so  well  described  by  Mr.  Ware ;  that  is,  I  could  see 
distant  objects  tolerably  well  with  the  former  number,  but  still  more 
accurately  with  the  latter.  After  contenting  myself  a  little  time 
with  No.  2,  I  laid  it  wholly  aside  for  No.  3  ;  and,  in  the  course  of 
a  few  more  years,  came  to  No.  5,  at  which  point  my  eye  has  now 
been  stationary  between  fifteen  and  twenty  years.     An  earlier  use 

*  Sir  C.  Blagden  here  employs  the  word  meniscus,  from  fumn,  the  moon,  in  a  sense, 
■which,  though  perhaps  vindicated  by  occasional  practice,  it  were  better  to  avoid.  A 
watch-glass  is  merely  a  segment  of  a  hollow  sphere,  the  surfaces  of  which  are  parallel. 


600 

of  concave  glasses  would  probably  have  made  me  more  near- 
sighted, or  would  have  brought  on  my  present  degree  of  rnyopy  at 
an  earlier  period  of  hfe.  If  ray  friends  had  persuaded  me  to  read 
and  wi'ite  with  the  book  or  paper  always  as  far  from  my  eye  as  I 
could  see ;  or  if  I  had  occasionally  intermitted  stud}",  and  taken  to 
field  sports,  or  any  employment  which  would  have  obliged  me  to 
look  much  at  distant  objects,  it  is  very  probable  that  I  might  not 
have  been  near-sighted  at  all."* 

When  once  a  near-sighted  person  has  experienced  the  pleasure 
of  seeing  remote  objects,  with  that  distinctness  and  comparative 
brilliancy,  which  the  aid  of  concave  glasses  affords,  it  is  not  easy 
to  persuade  him  to  renounce  their  use.  Their  efTect,  as  is  now 
universally  known,  is  merely  to  diverge  the  rays  of  hght  before 
these  enter  the  eye,  by  this  means  counteracting  the  over-refractive 
power  of  the  organ,  and  bringing  the  rays  of  light  exactly  into  foci 
upon  the  retina.  The  assistance  afforded  by  concave  glasses  to 
one  set  of  defective  eyes,  and  by  convex  to  another,  had  been  the 
subject  of  admiration  and  perplexity  for  several  hundred  years,  till 
Kepler,  in  his  Ad  Vitellionem  Pm^alipotneiia,  published  in  1604, 
cleared  up  the  mystery,  by  explaining,  for  the  first  time,  the  true 
mechanism  of  the  eye.  It  had  been  proposed  as  a  question  to 
Kepler,  by  his  patron,  Dietrickstein,  in  what  manner  spectacles 
assisted  sight.  The  first  answer  he  gave  was,  that  convex  glasses 
were  of  use,  by  making  objects  appear  larger.  But  his  patron  ob- 
served, that  if  objects  were  by  them  rendered  more  distinct,  because 
larger,  no  person  would  be  benefitted  by  concave  glasses,  since 
these  diminished  objects.  The  striking  resemblance  between  ex- 
periments with  the  camera  obscura  and  the  manner  in  which 
vision  is  performed  in  the  eye,  had  been  pointed  out  by  Baptista 
Porta,  who  compared  the  pupil  to  the  hole  in  the  window-shutter, 
but  fell  into  the  mistake  of  supposing  that  it  was  the  crystalline 
lens  which  corresponded  to  the  wall  which  receives  the  images. 
Kepler,  in  the  work  above  referred  to,  showed  that  this  office  is  per- 
formed by  the  retina,  and  gave  the  first  clear  explanation  of  the 
effects  of  lenses,  whether  within  or  without  the  eye,  in  making  the 
rays  of  a  pencil  of  light  converge  or  diverge.  He  now  explained, 
that  convex  glasses  assist  the  sight  of  presbyopic  persons,  by  so 
altering  the  directions  of  rays  diverging  from  a  near  object,  that 
they  should  afterwards  fall  upon  the  eye,  as  if  they  had  proceeded 
from  a  more  remote  one,  and  that  concave  glasses  benefit  the 
myopic,  by  producing  a  contrary  effect  upon  rays  which  diverge 
from  a  distant  object — a  theory  to  which  no  addition  has  been 
made  by  any  succeeding  author. 

The  glasses  commonly  employed  for  the  assistance  of  myopic 
eyes  are  double  concaves,  of  equal  concavity  on  each  side.  Occa- 
sionally, however,  the  two  sides  are  made  of  unequal  depth.  A 
plano-concave  glass  might  answer ;  and  in  the  use  of  concavo-con- 

♦  Philooopliical  Transactions,  Vol.  ciii.  p.  110.     London,  1811. 


601 

vexes,  (the  exterior  surface  of  the  glass,  or  that  which  is  turned 
from  the  eye,  being  convex,  and  having  a  less  degree  of  curvature 
than  tiie  interior,  or  that  which  is  turned  towards  the  eye,  which  is 
concave),  there  is  supposed  to  be  a  considerable  advantage,  in  so  far 
as  they  allow  the  eyes  a  greater  degree  of  latitude  in  vision,  without 
fatigue,  whence  the  name  periscopic  glasses,  under  which  they 
have  been  latterly  recommended  by  Dr.  Wollaston. 

Myopic  persons  are  extremely  apt  to  adopt  the  use  of  a  single 
eye-glass,  against  which  v/e  ought  to  put  them  on  their  guard. 
Spectacles  are  always  preferable,  because  by  keeping  both  eyes  in 
action,  not  only  is  vision  rendered  brighter  and  easier,  but  the  la- 
bour of  each  eye  is  considerably  lessened.  Dr.  Wells  has  pointed 
out  another  reason,  why  glasses  should  be  employed  rather  in  the 
form  of  spectacles,  than  singly,  which,  though  it  applies  more  strong- 
ly to  the  use  of  convex  than  of  concave  glasses,  I  shall  here  intro- 
duce in  his  own  words. 

"  In  regard  to  such  spectacles  as  I  have  tried  upon  myself,  I  have 
always  found,  that  when  I  looked  with  them  at  objects,  placed  at 
moderate  distances  before  me,  my  optic  axes  passed  through  the 
glasses,  more  inwardly  than  their  centres.  With  respect,  therefore, 
to  spectacles  for  long-sighted  people,  as  the  inner  halves  of  their 
glasses  may  be  regarded  as  two  prisms,  whose  lefracting  angles  face 
each  other,  to  have  allowed  both  my  eyes  to  receive  through  them 
pencils  of  rays  from  the  same  point  of  an  object,  the  intervals  of  my 
pupils  must  have  been  less  than  was  necessary  for  that  purpose  in 
naked  vision, — the  consequence  of  which  would  be,  an  increase 
of  the  refractive  power  of  my  eyes.  Again ;  as  the  like  parts  of 
glasses  in  spectacles  for  short-sighted  persons,  may  be  esteemed  to 
be  two  prisms,  the  refracting  angles  of  which  are  turned  from  each 
other,  the  interval  of  the  pupils  must  have  been  increased,  and  the 
refracting  power  of  my  eyes  by  this  means  diminished,  when  I  look- 
ed at  an  object  through  them,  which  was  directly  before  me.  And 
effects  similar  to  what  I  have  mentioned,  must  have  followed  my 
viewing  objects  placed  oblicjuely,  through  glasses  of  both  kinds. 
Here  then  is  one  advantage,  which  persons  who  see  with  both  eyes, 
either  do  or  may  enjoy  from  spectacles,  but  which  they  cannot  de- 
rive from  using  single  glasses.  For  if  they  are  presbytic,  they  can 
see  an  object  by  the  means  of  them  with  a  higher  refractive  state 
of  the  eyes,  than  if  the  optic  axes  met  there,  as  in  naked  vision  ; 
and  if  myopic,  with  a  less.  It  is  also  worthy  of  remark,  that  this 
advantage  does  not  ultimately  tend  to  increase  the  evil,  which  first 
gives  occasion  for  spectacles.  On  the  contrary,  if  what  every  writer 
upon  vision  asserts  be  true,  that  we  are  apt  to  become  short  or  long- 
sighted, according  as  we  are  much  accustomed  to  view  near  or  dis- 
tant objects,  it  must  serve  to  diminish  that  evil.  In  support  of  this 
opinion,  I  shall  mention  a  fact,  with  which  I  have  been  made  ac- 
quainted by  Mr.  George  Adams,  of  this  place,  who  is  not  only  well 
skilled  in  the  theory  of  vision,  but,  from  his  situation,  as  an  artist, 
76 


has  better  opportunities,  than  most  persons,  of  learning  such  mat- 
ters. The  fact  is  this,  that  he  does  not  know  a  short-sighted  per- 
son, who  has  had  occasion  to  increase  the  depth  of  his  glasses,  if  he 
began  to  use  them  in  the  form  of  spectacles  ;  whereas  he  can  re- 
collect several  instances,  where  those  have  been  obliged  to  change 
their  concave  glasses  repeatedly,  for  others  of  higher  powers,  who 
had  been  accustomed  to  apply  them  to  one  eye  only."  * 

Double-concave  glasses  are  numbered  1,  2,  3,  &c.  beginning 
with  the  longest  focus,  or  shallowest  concavity.t  We  must  re- 
commend to  the  near-sighted  person  to  be  content  with  the  shal- 
lowest glass,  or  lowest  number,  which  answers  his  purpose.  If 
No.  1  enables  him  to  discern  distinctly  the  names  on  the  corners 
of  the  streets,  and  gives  a  decided  outline  to  objects  whose  dis- 
tance does  not  exceed  about  40  feet,  he  ought  not  to  have  recourse 
to  No.  2.  Objects  should  appear  clear  through  the  glass  which  is 
chosen  ;  but  if  it  makes  ihem  less  than  natural,  or  gives  them  a 
dazzling  or  glaring  appearance,  or  if  the  eye  feels  strained  or  fa- 
tigued after  looking  through  it  for  a  short  time,  it  is  too  deep,  and 
a  lower  number  should  be  selected. 

When  a  near-sighted  person  wishes  to  be  fitted  with  glasses,  the 
simplest  and  surest  plan  is  to  try  each  eye  with  a  series  of  them,  at 
an  optician's  shop.  It  may  happen,  however,  that  an  individual 
in  the  country  is  desirous  of  writing  to  town  for  concave  glasses, 
and  wishes  to  mention  the  focus  which  will  be  likely  to  suit  his 
eye.  This  may  be  ascertained  by  means  of  the  optometer,  as  im- 
proved by  Dr.  Young ;  but  as  this  instrument  is  not  always  at 
hand,  the  following  rules  may  be  followed. 

1.  If  the  near-sighted  person  is  desirous  of  assistance  in  seeing 
remote  objects,  i.  e.  beyond  200  or  300  yards,  the  focal  distance  of 
the  glasses  which  he  will  require  for  that  purpose,  should  be  the 
distance  at  which  a  small  object  appears  distinct  to  his  naked  eye. 

*  Experiments  and  Observations  on  several  Subjects  in  Optics,  p.  99.     London. 

t  The  gradations  of  concavity,  in  the  common  glasses  for  near-sighted  eyes,  are  not 
always  worked  to  a  certain  standard,  so  that  what  one  calls  No.  1,  another  rates  as 
No.  2,  and  so  on.  Neither  are  the  two  sides  always  ground  on  a  tool  of  the  same 
radius,  so  that  the  one  side  is  sometimes  deeper  than  the  other.  Mr.  Ramsdem  made 
the  first  number  of  his  concave  glasses  equivalent  to  a  convex  of  24  inches  focus,  i.  e. 
if  a  convex  of  that  focal  length  were  united  to  a  concave  No.  1,  the  combination  would 
be  equivalent  to  a  plane,  and  objects  would  appear  through  the  two  glasses  neither  larger 
nor  smaller  than  they  really  are.  No  2,  he  made  to  correspond  to  a  21  inch  convex ; 
No.  3  to  an  18 ;  and  so  on. 

The  following  are  the  foci  in  inches  of  the  concave  glasses  usually  kept  in  the  shops. 


No.  1     . 

.     48 

No.  5    . 

.     14 

No.  9     . 

.     5 

2     . 

.     36 

6    . 

.     12 

10    . 

.    4 

3    . 

.     24 

7    . 

.      9 

11     . 

.    3 

4    . 

.     18 

8     . 

.      7 

12     . 

.     2h 

The  focus  of  a  concave  lens  may  be  ascertained,  by  reflecting  from  its  surface,  upon 
an  opaque  body,  the  image  of  any  very  distant  luminous  object,  such  as  the  sun,  ob- 
serving when  the  image  becomes  smallest,  and  measuring  the  distance  between  the 
surface  of  the  lens  and  the  body  upon  which  the  image  is  received.  The  distance  will 
be  the  focus. 


603 

For  example,  if  he  reads  this  type  at  12  inches'  distance,  12  inches 
will  be  the  focus  of  the  concave  glasses  which  he  will  require  for 
seeing  distant  objects  distinctly. 

2.  If  the  glasses  wanted  are  intented  for  reading  with  or  seeing 
near  objects,  let  the  near-sighted  person  multiply  the  distance  at 
which  he  is  able  to  read  with  ease  with  the  naked  eye,  say  4  inches, 
by  the  distance  at  which  he  wishes  to  read,  say  12  inches  ;  divide 
the  product  48  by  the  difference  between  the  two,  which  in  this 
instance  is  8  ;  the  quotient,  6,  is  the  focal  length  of  the  glass  in 
inches,  which  is  required. 

It  is  a  very  common  error  with  those  persons  who  begin  to  use 
concave  glasses,  to  tire  of  those  which  they  first  employ,  and  have 
recourse  to  deeper  ones.  To  these  the  eyes  do  not  fail  (at  least  for 
a  tinie)  to  accommodate  themselves ;  but,  in  the  end,  the  patient 
who  thus  proceeds  from  one  degree  of  concavity  to  a  greater,  will 
find  it  difficult  to  obtain  glasses  sufficiently  deep  to  affiard  him  much 
assistance,  or  he  may  produce  such  weakness  of  the  retina,  or  am- 
blyopia, as  sliall  render  him  unfit  to  engage  in  any  ordinary  pur- 
suit. Near-sightedness  generally  continues,  as  has  been  already 
stated,  in  nearly  the  same  degree  during  the  greater  part  of  life. 
Therefore,  the  same  glass  will  continue,  for  man}'^  years,  to  afford 
precisely  the  same  assistance,  and  ought  not  to  be  heedlessly 
changed  for  one  of  deeper  concavity. 

Dr.  Kitchener  tells  us,  that  he  was  about  fifteen  years  old,  when 
he  first  discovered  that  he  could  not  discern  distant  objects  so  dis- 
tinctly as  people  who  have  common  eyes  usually  do.  "  Seeing," 
says  he,  "  that  I  could  not  see  what  persons  with  common  eyes  fre- 
quently pointed  out  to  me  as  well  deserving  rny» attention,  1  paid  a 
visit  to  ati  optician,  and  purchased  a  concave  eye-glass  No.  2.  Af- 
ter using  this  some  little  time,  I  accidentally  looked  through  a 
concave  No.  3,  and  finding  my  sight  much  sharper  with  this,  than 
with  No.  2,  had  my  spectacles  glassed  with  No.  3,  which  appeared 
to  affi)rd  my  eye  as  much  assistance  as  it  could  receive.  After  using 
No.  3  for  a  few  months,  I  chanced  to  look  throueh  No.  4,  and 
again  found  the  same  increase  of  sharpness,  &c.  wliich  I  perceived 
before  when  I  had  been  using  No.  2  and  first  saw  through  No.  3, 
therefore  concluded  that  I  had  not  yet  got  glasses  sufficiently  con- 
cave, and  accordingly  procured  No.  4 : — however,  this  soon  became 
no  more  stimulus  to  the  optic  nerve  than  its  predecessors  Nos.  2 
and  3  had  been.  I  then  began  to  think  that  the  sight  was  sub- 
ject to  the  same  laws  which  govern  the  other  parts  of  our  system, 
i.  e.  an  increased  stimulus  by  repetition  soon  loses  iis  power  to  pro- 
duce an  increased  eflfect.  Therefore,  i  refused  my  eye  any  further 
assistance  than  it  received  from  spectacles  glassed  with  No.  2, 
which  I  have  worn  for  upwards  of  thirty-one  years,  and  it  is  very 
nearly,  if  not  quite  as  sufficient  help  to  me  now,  as  it  was  when  I 
first  employed  it."  * 

*  Economy  of  the  Eyes,  Part  I.  p.  111.     London,  1826. 


604 

The  same  author  recommends  persons  who  are  extremely  short- 
sighted, in  order  to  prevent  their  being  obhged  to  stoop  in  writing, 
reading  music,  and  the  like,  to  wear  spectacles  with  very  shallow 
concaves,  just  enough  to  enable  them  to  see  the  objects  required 
in  such  cases,  at  the  same  distance  with  other  persons  ;  but  for  dis- 
tant objects,  to  use  a  small  opera-glass,  which  having  an  adjustable 
focus,  if  it  magniiies  only  twice,  will  be  infinitely  better  than  any 
single  concave,  because  it  can  be  exactly  adapted  to  the  various  dis- 
tances. 

It  is  advisable  that  near-sighted  persons  should  not  wear  spec- 
tacles constantly,  but  only  on  occasions  when  they  more  particu- 
larly require  such  assistance.  When  they  have  been  worn  for  a 
considerable  time,  the  person  does  not  at  first  see  so  vrell  on  leav- 
ing them  ofif  as  he  did  before  ;  but  this  is  only  temporary. 


SECTION  II. PRESBYOPIA,*  OR  FAR-SIGHTEDNESS. 

Although  this  state  of  defective  vision,  the  general  nature  of 
which  has  been  explained  at  the  beginning  of  the  last  section,  oc- 
casionally occurs,  like  myopia,  suddenly,  and  at  any  period  of 
hfe,  yet,  in  by  far  the  greater  number  of  instances,  it  is  merely 
part  of  the  changes,  which  the  human  system  undergoes  at  the 
approach  of  old  age.  The  refractive  powers  of  the  eye  growing  too 
feeble,  or  its  axis  becoming  shorter  than  natural,  the  raj's  of  hght 
are  not  converged  sufficiently  soon,  to  be  brought  into  focal  points 
upon  the  retina.  The  image,  therefore,  is  diffused,  and  the  per- 
ception indistinct ;  ,to  remedy  which,  the  individual  moves  the  ob- 
ject of  examination  to  a  greater  distance  from  his  eye  than  his 
previous  point  of  distinct  vision,  by  this  means  counteracting  the 
tendency  of  the  rays  of  light,  proceeding  from  the  object  when  at 
the  usual  distance,  to  collect  into  foci,  not  upon  the  retina,  but 
behind  it. 

Symptoms  of  Presbyopia.  It  is  on  an  average,  about  the  age 
of  forty-five  years,  that  we  discover,  that,  especially  by  candle-light, 
w^e  see  near  objects  less  perfectly,  and  that  we  are  obliged  at  once 
to  illuminate  them  more  strongly,  and  remove  them  farther  from 
the  eye  than  formerly.  The  discovery,  that  the  eye  is  thus  be- 
ginning to  be  impaired  by  age,  is  gradually  made,  in  consequence 
of  the  difficulty  which  the  individual  experiences  in  reading  small 
print,  nibbing  his  pen,  threading  her  needle,  and  the  hke.  On  at- 
tempting to  examine  any  small  object  close  at  hand,  its  outline  be- 
comes obscure,  as  if  it  were  seen  through  a  mist;  very  minute  ob-' 
jects,  such  as  the  characters  of  a  small-printed  book,  are  either 
not  discerned  at  all,  or  they  seem  to  run  into  one  another,  or  to 
appear  double  ;  and  if  the  attempt  to  see  such  objects  is  persevered 
in,  the  eyes  soon  feel  fatigued,  and  the  head  begins  to  ache.     Dis- 

*  From  TTcio^u;,  old,  and  »>j,,  the  eye;  this  being  a  state  of  vision  to  which  old  age 
is  almost  invariably  subject. 


605 

tant  objects  continue  to  be  seen  as  before.  The  person  can  read 
a  distant  inscription,  or  tell  the  hour  by  a  distant  church  clock, 
when  he  cannot  read  a  common  printed  book  held  in  his  hand,  or 
see  the  figures  and  hands  of  a  watch. 

As  age  continues  to  advance,  the  presbyopic  defect  generally  be- 
comes more  and  more  decided,  the  eye  appears  to  lose  more  and 
more  the  power  of  discerning  near  objects  with  distinctness,  so  that 
the  individual,  unless  he  has  recourse  to  the  aid  of  glasses,  is  forced 
to  renounce  all  employments  which  require  minute  inspection ; 
or,  if  he  has  begun  the  use  of  glasses,  he  is  obliged  to  change  them 
from  time  to  time,  in  proportion  as  the  refractive  power  of  his  eyes 
decreases.  There  are,  however,  great  differences  in  the  progress  of 
far-sightedness  in  different  individuals.  Some  eyes  at  thirty  years 
of  age,  require  the  aid  of  convex  glasses  as  much  as  others  do  at 
fifty,  while  the  sight  of  certain  individuals  continues  almost  as  perfect 
at  fifty  as  it  was  at  thirty.  Young  men  of  twenty  sometimes  cannot 
see  to  read  or  write  without  convex  glasses  of  six  or  eight  inches 
focus,  while  persons  of  eighty  years,  and  upwards,  are  occasionally 
met  with,  who  are  able  to  read  even  a  small  print  without  assist- 
ance. Some,  after  commencing  the  use  of  spectacles,  are  obliged 
every  few  years  to  change  them  for  others  of  shorter  focus ;  others 
change  them  only  once  or  twice  in  the  course  of  a  prolonged  old 
age,  or  continue  for  perhaps  forty  years  together  to  see  satisfactori- 
ly with  the  aid  of  the  same  glasses.  These  and  similar  differ- 
ences depend  upon  the  original  formation  of  the  eyes,  how  they 
have  been  used,  and  the  general  health  and  constitution  of  the  in- 
dividual. 

The  few,  who,  after  the  age  of  forty,  can  see  quite  as  well  by 
candle-light,  as  they  could  before  that  age,  will  generally  find  that 
there  is  a  small  degree  of  shortness  in  their  sight,  which  is  the 
cause  of  their  possessing  that  advantage  longer  than  persons  in 
general  do.  If  they  try  a  very  shallow  concave  glass,  they  will 
find  it  give  a  decided  outhne  to  distant  objects,  which  they  never 
saw  defined  so  sharply  before. 

Instances  occasionally  occur  of  old  persons,  long  accustomed  to  use 
convex  glasses  of  considerable  power,  recovering  their  former  sight 
at  the  advanced  age  of  eighty  or  ninety  years,  so  that  they  no 
longer  required  any  artificial  assistance  even  in  reading.  Dr. 
Porterfield  was  led  to  attribute  this  remarkable  amendment  to  a 
decay  of  the  adipose  substance  at  the  bottom  of  the  orbit,  in  con- 
sequence of  which,  he  supposes,  that  the  eye,  from  a  want  of  its 
usual  support,  will  be  brought  by  pressure  of  the  muscles  on  its  sides, 
into  a  kind  of  oval  figure,  in  which  state  the  retina  will  be  removed 
to  a  due  distance  from  the  flattened  cornea.*  Mr.  Ware  objects 
to  this  explanation,  that  we  never  see  a  morbid  accumulation  of 
adipose  substance  in  the  orbit  produce  presbyopia,  but  that,  on  the 

*  Treatise  on  the  Eye.    Vol.  ii.  p.  70.  Edinburgh,  1769. 


606 

contrary,  myopia  is  sometimes  induced  by  that  cause ;  and  thinks 
it  more  probable,  that  the  remarkable  revolution  in  question  is^oc- 
casioned  by  an  absorption  of  part  of  the  vitreous  humour,  in  con- 
sequence of  which  the  sides  of  the  sclerotica  are  pressed  inward, 
and  the  axis  of  the  eye  proportionably  lengthened.* 

Although  the  eye,  after  middle  hfe,  loses  the  power  of  distinguish- 
ing near  objects  with  correctness,  it  generally  retains  the  sight  of 
those  that  are  distant.  Instances,  however,  are  not  wanting  of  per- 
sons of  advanced  age,  requiring  the  aid  of  convex  glasses  to  enable 
them  to  see  distant,  as  well  as  near,  objects.  Thus,  Dr.  Wells 
informs  us,  that  when  twenty  years  younger,  he  was  able,  with  his 
left  eye,  to  bring  to  a  focus  on  the  retina,  pencils  of  rays  which  flowed 
from  every  distance  greater  than  seven  inches  from  the  cornea  ;  but 
by  the  time  he  reached  the  age  of  fifty-five,  his  eyes  had  altered 
considerably,  with  respect  to  their  seeing  near  objects  distinctly,  and 
he  had,  in  consequence,  been  obliged,  not  only  to  use  convex  glasses, 
but  to  change  them  several  times  for  others  of  higher  power. 
On  carefully  examining  the  state  of  his  sight,  previously  to  the 
repetition  of  some  optical  experiments,  he  found,  to  his  great  surprise, 
that  the  power  of  adapting  his  eyes  to  different  distances  was  com- 
pletely gone,  in  other  words,  that  he  was  obliged  to  regard  all  objects, 
whether  near  or  remote,  in  the  same  refractive  state  of  those  organs. 
He  found  that  he  required  not  only  a  convex  glass  of  six  inches 
focus,  to  enable  him  to  bring  to  a  point  on  the  retina  rays  proceed- 
ing from  an  object  seven  inches  from  the  eye,  but  likewise  a  convex 
glass  of  thirty-six  inches  focus,  to  enable  him  to  bring  to  a  point 
parallel  rays.t 

The  objective  symptoms,  which  generally  attend  presbyopia,  are 
an  apparent  diminution  in  the  size  of  the  eyeball,  which  is  also 
more  sunk  in  the  orbit ;  flatness  of  the  cornea,  shortening  of  the 
axis  of  the  anterior  chamber,  and  smallness  of  the  pupil. 

Causes.  There  can  be  no  doubt  that  deficient  refraction  is  the 
proximate  cause  of  presbyopia,  and  that  it  is  intimately  connected 
with  the  decline  of  life.  It  is  also  said  that  it  is  more  apt  to  occur 
in  those  who  have  used  their  eyes  much  upon  remote  objects. 

With  regard  to  the  efficient  causes,  flatness  of  the  cornea  from 
diminution  in  the  quantity  of  the  aqueous  and  vitreous  humours 
is  the  one  most  frequently  mentioned,  this  diminution  being  sup- 
posed to  depend  on  the  impeded  manner  in  which  the  function  of 
secretion  is  performed  in  advanced  life. 

Diminished  density  of  any  of  the  refractive  media  of  the  eye,  or 
diminished  convexity,  will  prove  a  sufficient  cause  of  presbyopia. 
So  far  as  the  crystalline  lens  is  concerned,  it  is  generally  admitted 
that  its  density  increases  as  age  advances,  which  should  tend  to 
counteract  any  presbyopic  tendency  arising  from  flattening  of  ihe  cor- 
nea or  deficiency  of  the  aqueous  or  vitreous  humours.     At  the  same 

*  Philosophical  Transactions,  Vol.  ciii.  p.  42.  London,  1813. 
t  Philosophical  Transactions,  Vol.  ci.  p  380.   London,  1811. 


607 

time,  the  increase  of  density  of  the  lens  may  possibly  be  attended  by 
a  degree  of  shrinking,  by  which  its  form  may  be  rendered  less  con- 
vex, and  its  refractive  power  diminished. 

It  appears  to  be  the  general  opinion,  that  along  with  diminished 
refraction,  there  attends  upon  presbyopia  a  loss  of  that  power  of  ac- 
commodation to  the  perception  of  near  objects,  which  is  possessed 
by  the  healthy  eye.  Whether  this  power  depends  on  a  change  of 
form  or  of  place  in  the  crystalline  lens,  or  on  both  of  these,  or  some 
change  different  from  either,  it  is  easily  conceivable  that  a  partial 
or  total  loss  of  this  power  would  be  quite  analogous  to  the  diminish- 
ed activity  which  takes  place  in  all  the  functions  of  the  body  on  the 
approach  of  old  age. 

Treatment.  Although  it  would  be  in  vain  to  expect  any  plan 
of  treatment  to  have  the  effect  of  removing,  or  perhaps  even  lessen- 
ing a  degree  of  presbyopia  already  produced,  it  is  but  reasonable  to 
suppose  that  by  avoiding  whatever  over-fatigues  the  sight,  and  by- 
following  whatever  tends  to  delay  the  progress  of  decrepitude,  this 
defect  may  in  a  considerable  measure  be  warded  off.  It  is  only  to 
such  influences,  added  to  an  original  soundness  of  constitution,  that 
we  can  attribute  the  exemption  from  presbyopia,  which  is  occasion- 
ally possessed  by  men  far  advanced  in  life. 

The  assistance,  which  the  presbyopic  eye  derives  from  a  double 
convex-glass,  ought  neither  to  be  too  soon  had  recourse  to,  nor  too 
long  delayed.  Many  injure  their  sight,  by  adopting  the  use  of 
magnifiers  suddenly,  and  before  they  have  any  need  of  them ; 
while  others,  actuated  perhaps  by  a  desire  of  concealing  their  age, 
refrain  from  employing  them  long  after  the  period,  when  they 
would  not  merely  have  afforded  them  a  valuable  assistance,  but 
have  proved  a  means  of  saving  their  sight.  The  presbyopic  eye, 
if  refused  the  aid  of  glasses,  is  necessarily  strained  by  every  attempt 
to  perceive  near  objects,  and  suffers  more  in  a  few  months  by  such 
forced  exertion,  that  it  would  do  in  as  many  years,  if  assisted  by 
such  glasses  as  would  render  vision  easy  and  agreeable. 

It  would  evidently  be  absurd  to  fix  upon  any  period  of  life  at 
which  glasses  should  be  first  employed,  or  at  which  the  presbyopic 
eye  should  be  assisted  by  stronger  magnifiers  than  those  which 
the  individual  has  made  choice  of  in  the  first  instance ;  but  it  may 
be  laid  down  as  a  general  rule,  that  whenever  a  person  of  forty-five 
years  of  age,  or  upwards,  finds,  that  in  order  to  see  small  objects 
distinctl}^,  he  is  obliged  to  carry  them  far  from  his  eye ;  that  he 
moves,  as  it  were  instinctively,  nearer  to  the  light,  when  he  wishes 
to  read  or  work,  or  holds  the  book  or  other  object  close  to  the  light, 
in  order  to  see  with  facility ;  that  very  small  objects,  after  he  has 
looked  at  them  earnestly  for  some  time,  appear  confused ;  that  his 
eyes,  after  slight  exertion,  become  so  much  fatigued,  that  he  is 
obliged  to  turn  them  to  other  objects,  in  order  to  give  them  some 
relaxation ;  and  that  the  sight,  on  awaking  in  the  morning,  is 
very  weak,  and  does  not  recover  its  customary  degree  of  force  for 


608 

some  hours ;  then,  he  may,  if  he  has  not  hitherto  used  convex 
glasses,  begin  to  use  them,  or  if  he  has  ah"eady  had  recourse  to 
those  of  a  very  long  focus,  he  may  change  them  for  a  pair  of 
shorter  focus,  or,  in  other  words,  of  greater  refractive  power. 

A  double-convex  glass  improves  the  vision  of  a  presbyopic  eye, 
simply  by  lessening  the  divergence  of  the  rays  of  light  proceeding 
from  near  objects,  and  thus  ensuring  their  being  brought  into  foci 
upon  the  retina.  To  see  distant  objects  with  distinctness,  glasses 
are  in  general  not  required  by  the  presbyopic  eye  ;  on  the  contrary, 
parallel  rays  being  sufficiently  converged  by  the  refractive  media 
of  the  eye  itself,  to  be  brought  to  their  respective  foci  on  the  retina, 
the  convex-glasses  must  be  laid  aside,  when  objects  at  a  distance 
are  to  be  examined. 

As  a  meniscus  will  produce  the  same  effect  as  a  double-convex 
glass,  in  enabling  the  presbyopic  eye  to  perceive  near  objects  with 
distinctness,  while  it  will  allow  the  eye  greater  latitude  without  fa- 
tigue, Dr.  Wollaston  has  recommended  the  former  as  a  pe7'iscopic 
glass  for  far-sighted  persons. 

Similar  directions  must  be  followed  in  choosing  convex  glasses 
as  in  selecting  concave  ones ;  viz.  that  each  eye  is  to  be  tried  sep- 
arately :  that  the  lowest  powei\  or  longest  focus,  which  answers 
the  purpose,  is  to  be  chosen  :  and  that  as  the  concave  glasses  made 
use  of  b}^  the  near-sighted  should  not  make  objects  appear  smaller, 
neither  should  the  convex  glasses  employed  by  the  far-sighted  make 
them  appear  larger  than  natural.* 

Persons  at  a  distance  from  an  optician,  may  determine  the  focal 
length  of  the  convex  glasses,  which  they  will  require,  by  means 
of  the  following  rules. 

1 .  If  the}'  have  a  distinct  vision  of  objects  tnoderately  remote, 
let  them  multiply  the  distance  at  which  they  see  minute  objects 
most  distinctly,  say  20  inches,  by  the  distance  at  which  they  wish 
to  read  by  the  aid  of  glasses,  say  12  inches,  and  divide  the  product, 
240,  by  the  difference  between  the  two,  S ;  the  quotient,  30,  will 
be  the  focal  length  of  the  glasses  required. 

2.  If  the  distance  at  which  the  person  sees  most  distinctly 
be  very  great,  then  the  focal  length  of  the  glasses  required  will 
be  equal  to  the  distance  at  which  be  wishes  to  see  objects  most  dis- 
tinctly. 

Convex  glasses  of  about  thirty-six  inches  focus  are  often  used  by 

*_  Convex  glasses  are  kept  in  the  shops  of  every  focal  length  from  thirty-six  inches 
to  six.  It  is  evident,  that  no  certain  estimate  can  be  formed  from  a  person's  age,  of 
the  focal  length  of  the  glass  which  he  will  require  ;  although  perhaps  the  following 
may  be  received  as  a  tolerable  approximation  to  an  average,  upon  this  head. 

Tears   of  age •.    40  45   50   55   58   60   65   70   75  80  85   90   100 

Focal   lengths  in  inches,    ...    36   30  24  20   18    16   14   12   10     9     8     7       6 

The  focus  of  a  convex  glass  may  be  measured  by  holding  it  near  the  side  of  a  room, 
facing  a  window,  or  what  is  still  better,  opposite  to  a  candle,  and  moving  it  slowly 
backwards  and  forwards,  until  the  image  of  the  window-frame,  or  of  the  flame  of  the 
candle,  upon  the  wall,  becomes  smallest  and  most  distinct.  The  distance  between  the 
glass  and  the  wall  at  that  moment  is  the  focal  length. 


609 

ignorant  people,  under  the  name  of  preservers,  before  their  sight 
has  attained  that  degree  of  presbyopia,  which  renders  the  use  of 
glasses  necessary.  They  seem  to  think  that  preservers  have  the 
power  of  arresting  the  progress  of  that  failure  of  the  sight,  which 
is  the  natural  consequence  of  age. 

As  it  is  chiefly  by  candle-light  that  the  presbyopic  patient  com- 
plains of  his  deficient  sight ;  even  after  he  has  suppHed  himself 
with  proper  glasses,  it  is  advisable  that  he  should  refrain,  as  much 
as  possible,  from  employing  himself  at  night  in  occupations,  which 
require  intense  use  of  the  organs  of  vision.  The  moment  that 
the  eyes  begin  to  feel  hot  and  fatigued,  while  the  individual  is  oc- 
cupied in  reading,  writing,  or  the  like,  especially  by  candle-hght, 
he  should  take  the  hint,  and  allow  them  a  period  of  repose. 

When  presbyopia  occurs  suddenly  in  subjects  much  under  the 
age  of  forty  years,  it  will  lead  us  to  suspect,  either  some  derange- 
ment of  the  internal  parts  of  the  eye,  some  pressure  behind  the 
eyeball,  or  some  disease  of  that  portion  of  the  optic  apparatus  which 
is  contained  within  the  cranium.  Instances  of  this  sort  have  oc- 
curred even  in  children,  and  have  sometimes  yielded  to  the  use  of 
evacuating  remedies.  Thus,  Mr.  Ware  mentions  the  case  of  a 
boy  of  eight  years  old,  who  suddenly  became  presbyopic,  and  was 
repeatedly  punished  at  school,  on  account  of  his  incorrect  and  de- 
faced writing,  the  real  cause  being  unknown  to  his  master.  After 
the  presbyopia  had  continued  a  fortnight,  and  different  local  appli- 
cations had  been  used  without  producing  any  sensibly  good  effects, 
cure  was  accomplished  by  the  application  of  leeches  to  the  tem- 
ples, and  the  use  of  purgative  medicines.  Two  sisters  of  this  pa- 
tient were  similarly  affected.  The  elder,  twenty  years  of  age,  had 
never  been  able  to  do  fine  work,  and  for  three  years  had  been 
greatly  assisted  by  convex  spectacles.  The  younger,  a  girl  of  fif- 
teen, had  been  presbyopic  for  about  a  year,  being  obliged  to  use 
glasses  whenever  she  read,  or  worked  with  her  needle.  This  pa- 
tient, in  the  course  of  six  weeks,  during  which  she  totally  abstained 
from  the  use  of  glasses,  was  completely  relieved  from  the  necessity 
of  using  them,  by  the  apphcation  of  two  leeches  to  each  temple 
twice  a  week.  The  eldest  sister,  in  the  same  space  of  time,  expe- 
rienced much  relief  from  similar  treatment,  but  was  still  unable  to 
do  fine  work  without  glasses,  partly  in  consequence  of  the  long 
continuance  of  the  infirmity,  and  partly  on  account  of  her  not 
having  abstained  from  the  use  of  her  spectacles  with  equal  steadi- 
ness.* 


SECTION    III. INSENSIBILITY  TO  CERTAIN  COLOURS. 

Numerous  instances  have  now  been  recorded  of  persons,  who  were 
liable  to  strange  mistakes  regarding  the  colours  of  objects,  or  were 

*  Philosophical  Transactions,  Vol.  ciii.  p.  48.     London.  1813. 

77 


610 

even  totally  unable  to  perceive  certain  colours.  Some  of  the  indi- 
viduals in  question  appear  to  have  been  myopic,  but  the  eyes  of 
most  of  those  who  presented  this  defect  are  described  as  appearing 
in  no  way  diseased  or  unnatural,  and  to  have  fulfilled  their  func- 
tions perfectly,  so  far  as  the  size,  form,  and  distance  of  objects  were 
concerned. 

Mr.  Huddart  mentions  the  case  of  one  Harris,  a  shoe-maker  at 
Maryport  in  Cumberland,  who  could  distingush  only  black  and 
white,  and  who  had  two  brothers  almost  equally  defective,  one  of 
whom  always  mistook  orange  for  green.  Harris  observed  this 
defect  when  he  was  four  years  old.  Having  by  accident  found  in 
the  street  a  child's  stocking,  he  carried  it  to  a  neighbouring  house 
to  inquire  for  the  owner :  he  observed  the  people  called  it  a  red  stock- 
ing, though  he  did  not  understand  why  they  gave  it  that  demoni- 
nation,  as  he  himself  thought  it  completely  described  by  being  called 
a  stocking.  The  circumstance,  however,  remained  in  his  memo- 
ry, and  together  with  subsequent  observations,  led  him  to  the  knowl- 
edge of  his  defects  He  observed,  for  instance,  that  other  children  could 
discern  cherries  on  a  tree  by  some  pretended  difference  of  colour, 
though  he  could  distinguish  them  from  the  leaves  by  their  difierence 
only  of  size  and  shape.* 

Another  case,  of  a  Mr.  Scott,  is  recorded,  to  whom  full  reds  and 
full  greens  appeared  alike,  while  yellows  and  dark  blues  were  vary 
easily  distinguished.  3L'.  Scott's  father,  his  maternal  uncle, 
one  of  his  sisters,  and  her  two  sons,  had  all  the  same  imperfec- 
tion.t 

Mr.  Dalton,  the  celebrated  chemist,  cannot  distinguish  pink 
from  blue,  by  daylight ;  and  in  the  solar  spectrum,  the  red  is 
scarcely  visible  to  him,  the  rest  of  it  appearing  to  consist  of  two 
coloLU's,  yellow  and  blue.  He  appears  to  have  remained  long  un- 
conscious of  his  defect ;  and  was  led,  rather  to  suppose  that  there 
existed  some  perplexity  in  the  nomenclature  of  colours,  than  any 
incapabihty  in  his  own  power  of  distinguishing  them.t 

Those  W'ho  feel  inclined  to  examine  the  particulars  of  other  in- 
stances of  this  sort,  may  consult  the  work  referred  to  in  the  note. 5 
They  w^ill  find,  on  doing  so,  that  the  chief  peculiarities  of  these 
cases  are,  the  confounding  of  red  with  green,  and  pink  with  blue; 
in  other  words,  that  red  light,  colours  in  which  it  forms  an  ingre- 
dient,  and  its  accidental  colour,  are  not  distinguishable  by  those 
who  labour  under  the  defect  in  question.     Red  appears  to  them 

*  Phil.  Trans,  vol.  Ixvii.  p.  260.  Lond.  1777.     t  Ibid.  vol.  Ixviii.  p.  611.  Lond.1779. 

t  Memoirs  of  the  Literary  and  Philosophical  Society  of  Manchester.  1st  Series. 
Vol.  V.  p.  2.9.     Manchester^  1798. 

§  Nicholl  in  McJico-Chirur^cal  Transactions,  Vol.  vii .  p.  477,  and  Vol.  ix.  p.  359 ;. 
and  in  Annals  of  Philosophy,  Xew  Series,  Vol.  iii.  p.  1-23. — Butter  in  Transactions 
of  the  Phrenological  Society,  p.  209. — Combe,  ibid.  p.  222. — Harvey  in  Transactions 
of  the  Royal  Society  of  Edinburgh,  Vol.  x.  p.  253,  and  in  Edinburgh  Joiarnal  of 
Science,  Vol.  v.  p.  114. — Article  Light,  in  Encyclopaedia  Metropolitana,  p.  434, 
§  507. — Brewster  in  Edinburgh  Journal  of  Science,  Vol.  iv.  p.  85. — Phrenological 
Journal,  Vol.  iii.  p.  265. — Colquhoun  in  Glasgow  Medical  Journal,  Vol.  ii.  p.  12. 


611 

merely  a  dark  colour,  and  green  a  shade  of  drab.  Yellow  and 
blue  they  readily  distinguish ;  but  tliey  judge  of  orange,  purple, 
and  brown  with  great  difficulty ;  and  even  the  shades  of  black, 
grey,  and  white,  they  are  often  unable  to  decide  upon  without  hesi- 
tation. 

We  should  scarcely  suppose,  that  a  deficiency  in  the  perception 
of  colours  could  be  attended  with  any  advantage  ;  yet  in  one  res- 
pect, this  appears  to  be  the  case.  "  1  see  objects,"  says  one  of  the 
subjects  of  this  defect,  "  at  a  greater  distance  and  more  distinctly 
in  the  dark  than  any  one  I  recollect  to  have  met  with  ;  this  I  dis- 
covered many  years  before  I  was  aware  of  my  defective  errors  in 
colours."  *  Another  makes  the  following  observations  on  the  same 
point.  "  All  objects  whatever,  when  viewed  at  a  distance,  lose  their 
local  colouring,  and  assume  more  or  less,  of  a  pale,  or  azure  blue 
tinge,  which  painters  term  the  colour  of  the  air,  which  is  inter- 
posed between  the  spectator,  and  the  distant  object.  No  colour 
contrasts  to  me  so  forcibly  with  black  as  this  azure  blue,  and  as 
you  know  that  the  shadows  of  all  objects  are  composed  of  black,  the 
forms  of  objects  which  have  acquired  more  or  less  of  this  blue  hue, 
from  being  distant,  become  defined,  and  marked  by  the  possession 
of  shadows,  which  are  invisible  to  me  in  the  high-coloured  objects 
in  a  fore-ground,  and  which  are  thus  left  comparatively  confused, 
and  shapeless  masses  of  colour.  So  much  is  this  the  case  with 
me,  when  viewing  a  distant  object,  as  to  overcome  the  effect  of 
perspective,  and  the  shading  in  the  form  and  the  garments  of  hu- 
man beings  at  some  distance  from  my  eye,  is  often  so  predomi- 
nant, and  marks  them  so  distinctly,  as  to  overcome  the  effect  of 
diminution  of  size ;  and  although  I  see  the  object  most  distinctly,  I 
am  unable  to  tell  whether  it  be  a  child  near  me,  or  a  grown-up 
person  at  a  considerable  distance."  t 

Causes.  The  following  are  some  of  the  notions  which  have 
been  formed  regarding  the  probable  causes  of  insensibility  co  colours. 

i.  Mr.  Dalton  thinks  it  probable  that  the  red  light  is,  in  these 
cases,  absorbed  by  the  vitreous  humour,  which  he  supposes  may 
have  a  blue  colour ;  a  very  unlikely  conjecture,  at  the  best,  but 
which  appears  to  be  refuted  by  the  simple  experiment  of  looking 
through  a  pair  of  green  or  blue  glasses.  When  we  do  so,  we  still 
recognise  every  primitive  colour  in  bodies,  with  a  shade  merely  of 
green  or  blue  over  them.  Therefore,  supposing  the  rays  of  hght 
to  pass  through  a  blue  vitreous  humour,  it  does  not  follow  that  ob- 
jects should  appear  blue,  or  that  we  should  be  prevented  from  dis- 
cerning red  light,  or  any  other  colour.  In  old  age,  we  view  all 
objects  through  an  amber-coloured  crystalUne  lens,  and  yet  see 
every  thing  of  its  natural  hue. 

2.  A  writer  in  the  Edinburgh  Journal  of  Science,!  going  on  the 
supposition  that  the  choroid  coat  is  essential  to  vision,  gives  it  as 

*  Medico-Chirurgical  Transactions,  Vol.  ix.  p.  361.     London,  1818. 

1-  Glasgow  Medical  Journal,  Vol.  ii.  p.  14.     Glasgow,  1829;  t  Vol.  iv.  p.  86. 


612 

his  conjecture,  that  the  loss  of  red  light  in  the  subjects  of  this  de- 
fect, arises  from  the  retina  itself  having  a  blue  tint,  so  that  the 
light,  falhng  upon  the  choroid  coat,  being  deprived  of  its  red  rays 
by  the  absorptive  power  of  the  blue  retina,  the  impression  con- 
veyed to  the  retina  by  the  choroid,  will  not  contain  that  of  red 
light. 

3.  Dr.  Young,  adopting  apparently  the  notion  of  Darwin,  that 
the  retina  is  active  not  passive  in  vision,  regards  it  as  the  simplest 
explanation  of  this  defect,  to  suppose  that  those  fibres  of  the  retina, 
which  are  calculated  to  perceive  red,  are  absent  or  paralyzed. 

4.  Dr.  Brewster  conceives  that  the  eye,  in  these  cases,  is  insensi- 
ble to  the  colours  at  one  end  of  the  spectrum,  just  as  the  ear  of  cer- 
tain persons  has  been  proved,  by  Dr.  WoUaston,  to  be  insensible  to 
sounds  at  one  extremity  of  the  scale  of  musical  notes,  while  it  is 
perfectly  sensible  to  all  other  sounds. 

5.  The  phrenologists  maintain,  that  the  faculty  of  distinguish- 
ing colours  does  not  depend  on  the  eye,  but  on  a  particular  part  of 
the  brain,  to  which  they  give  the  name  of  the  organ  of  colour  ; 
and  that  in  those  who  are  deficient  in  judging  of  colours,  the  defect 
lies  in  this  organ,  and  not  in  the  eyes,  the  mechanical  construction 
and  optical  effects  of  which  appear  to  be  perfect  in  the  individuals 
in  question. 


SECTION  IV. CHRUPSIAj*    OR   COLOURED  VISION. 

It  is  evident,  that  in  health  we  should  suffer  no  imitations  of  vis- 
ual sensations,  no  flashes  of  light  from  internal  changes  in  the  eye, 
no  false  perceptions  of  muscse  volitantes ;  that  we  should  see  ob- 
jects of  their  natural  colours,  not  tinged  with  hues  entirely  foreign 
to  them,  or  of  which  they  in  general  appear  to  be  free  ;  and  that 
we  should  have  the  consciousness  of  being  impressed  by  the  view 
of  external  objects,  only  when  such  objects  are  present  and  actually 
affecting  our  organs  of  vision.  Yet  such  is  the  constitution  of  the 
optic  apparatus,  that  by  various  derangements  to  which  it  is  liable, 
we  become  the  subjects  of  many  sensations,  which  have  actually 
no  prototype.  Even  a  mere  defect  of  power  in  this  apparatus  to  be 
affected  in  the  natural  way,  frequently  gives  rise  to  false  sensa- 
tions. 

Circulating  through  the  immediate  organ  of  visual  sensation,  the 
blood,  during  a  state  of  perfect  health,  makes  no  visual  impression 
on  that  organ ;  but  let  the  circulation  through  the  retina,  and 
neighbouring  parts,  be  either  accelerated  or  impeded,  and  certain 
morbid  sensations  are  immediately  produced.  One  of  these  is  what 
is  commonly  called  seeitig  the  circulation  of  the  blood  hi  the  eye. 
Thus  Sauvages  observed,  that  the  pulsations  of  the  ophthalmic 
artery  might  be  perceived,  by  looking  attentively  on  a  white  wall. 


From  Xi'^'h  colour,  and  o-^n,  \ision. 


613 

well  illuminated.  A  kind  of  network,  darker  tlian  the  other  parts 
of  the  wall,  appears  and  vanishes  alternately  with  every  pulsation. 
This  change  of  colour  of  the  wall  he  ascribes  to  the  compression  of 
the  retina,  by  the  diastole  of  the  artery,"  Dr.  R.  W.  Darwin,  also, 
describes  what  he  calls  seeing  the  circulation  of  the  blood  in  the 
eye.  "  The  circulation  may  be  seen,"  says  he,  "  either  in  both 
eyes  at  a  time,  or  only  in  one  of  them  ;  for  as  a  certain  quantity 
'of  light  is  necessary  to  produce  this  curious  phenomenon,  if  one 
hand  be  brought  nearer  the  closed  eyelids  than  the  other,  the  circu- 
lation in  that  eye  will,  for  a  time,  disappear.  For  the  easier  view- 
ing the  circulation,  it  is  sometimes  necessary  to  rub  the  eyes  with  a 
certain  degree  of  force  after  they  are  closed,  and  to  hold  the  breath 
longer  than  is  agreeable,  which,  by  accumulating  more  blood  in 
the  eye,  facilitates  the  experiment ;  but  in  general  it  may  be  seen 
distinctly  after  having  examined  other  spectra  with  your  back  to 
the  light,  till  the  eyes  become  weary  •  then  having  covei-ed  3i'our 
closed  eyelids  for  half  a  minute,  till  the  spectrum  is  faded  away, 
which  you  were  examining,  turn  ymiir  face  to  the  light,  and  re- 
moving your  hands  from  the  eyelids,  by  and  by  again  shade  them 
a  little,  and  the  circulation  becomes  curiously  distinct.  The  streams 
of  blood  are,  however,  generally  seen  to  unite,  which  shews  it  to  be 
the  venous  circulation,  owing,  I  suppose,  to  the  greater  opacity  of 
the  blood  in  these  vessels."  t 

In  this,  and  the  next  four  sections,  we  shall  notice  some  of  the 
most  remarkable  false  visual  sensations.  The  first  is  what  is  called 
'chrapsia,  or  coloured  vision. 

Patients,  who  are  partially  amaurotic,  complain  not  unfrequentlj 
'of  luminous  objects,  as,  a  Mghted  candle,  appearing  as  if  surrounded 
by  the  colours  of  the  rainbow-  This  symptom  has  been  called 
chrupsia,  and  has  been  supposed  to  depend  on  some  derangement 
of  the  lenses  of  the  eye,  by  which  the  achromatic  power  of  this  or- 
gan becomes  im.paired.  In  all  such  cases,  it  would  be  proper  to 
guard  against  our  being  deceived,  by  those  causes,  which  might 
induce  a  decomposition  of  the  rays  of  light  by  inflection  merely, 
such  as  contraction  of  the  eyelids. 

Another  variety  of  chrupsia,  consists  in  seeing  objects  of  a  differ- 
ent colour  from  that  which  is  natural  to  them.  Some  amaurotic 
patients  see  objects  as  if  tinged  of  a  yellow,  green,  or  bluish  colour, 

I  have  at  present  a  patient  under  my  care  with  prolapsus  of  the 
nasal  portion  of  the  iris  through  an  accidental  wound  of  the  cor- 
nea, who  sees  all  objects  of  a  greenish  hue. 

The  alleged  yellowness  of  objects  in  jaundice,  which,  if  it  ever 
occurs,  is  exceedingly  rare,  the  red  tinge  which  is  seen  by  the  pa- 
tient whose  anterior  chamber  is  filled  with  blood,  and  even  the 
phenomena  of  ocular  spectra  or  accidental  colours  have  all  been 
crowded  together  under  the  appellation  chrupsia. 

*  Nosologia  Methodica,  Vol.  ii.  p.  180.     Amstelodami,  1768. 
+  Philosophical  Transactions,  Vol.  Ixxvi.  p.  344.    London,  1786. 


614 


SECTION  V. PHOTOPSIA. 

That  sensations  of  light  may  be  excited  independently  of  the 
ordinary  impressions  from  external  objects,  is  familiarly  known. 
The  flash,  produced  upon  sneezing,  or  by  a  sudden  blow  on  the 
eye,  or  by  the  passage  of  tlie  Galvanic  influence  through  different 
parts  of  the  face,  as  in  the  simple  experiment  of  applying  a  piece 
of  zinc  and  a  piece  of  silver  to  the  tongue,  and  then  bringing  them 
into  contact,  is  generally  considered  as  sufficient  proof,  that  the 
retina  may  be  so  impressed,  as  to  produce  the  sensation  of  light, 
altogether  independent!}^  of  the  actual  presence  of  light.  The  ef- 
fect is  produced  whether  the  eyes  be  opened  or  closed,  and  whether 
the  experiment  be  made  in  daylight  or  in  the  dark. 

In  like  manner,  there  are  sensations  of  light,  which  are  alto- 
gether the  result  of  disease  in  the  optic  apparatus.  Flashes  of 
light,  the  appearance  of  shining  stars,  a  gUttering  as  if  from  the 
points  of  innumerable  needles,  and  a  variety  of  other  lucid  spectra 
attend  retinitis,  and  occur  in  the  commencement  of  certain  kinds 
of  amaurosis.  In  some  peculiar  and  distressing  cases,  the  patient 
is  annoyed  by  the  sensation  as  if  his  eyes  were  directed  towards 
globes  of  light  swimming  before  him,  or  as  if  he  were  looking  at 
a  sea  of  melted  goJd. 

The  distress,  which  patients  affected  with  such  false  sensations 
experience,  varies  greatly  in  degree ;  but,  on  the  whole,  these  lucid 
spectra  are  both  less  supportable  by  those  who  experience  them, 
and  ought  to  be  regarded  as  of  a  more  alarming  nature,  than  the 
semi-transparent  or  dark  muscm  volitantes,  which  so  frequently 
occur.  Flashes  of  light  are  often  the  precursors  of  convulsive  at- 
tacks, such  as  epilepsy ;  subjects  inchned  to  apoplexy,  on  raising 
their  heads  after  stooping,  see  showers  of  shining  spectra ;  those 
who  have  suffered  from  internal  ophthalmia  are  often  troubled  with 
such  sensations  as  that  of  a  luminous  wheel,  rapidly  revohing 
before  them;  and  phrenitis  is  attended  by  false  impressions  of  the 
same  sort,  which  often  continue  long  after  all  the  other  symptoms 
have  ceased. 

It  is  of  great  Importance,  to  ascertain  the  cause  of  photopsia,  and 
to  distinguish  it  accurately  from  photophobia.t  The  latter  often 
stimulates  the  former,  especially  in  strumous,  hypochondriacal,  and 
hysterical  patients.  The  cause  of  photopsia  being  discovered,  the 
line  of  treatment  can  scarcely  be  mistaken. 

Case.  The  following  interesting  case  of  photopsia  has  been 
recorded  by  Mr.  Ware,  in  the  words  of  the  patient  himself,  a  med- 
ical practitioner. 

"  About  ten  years  ago,  when  about  forty-eight  years  of  age,  I 
experienced  the  first  attack  of  the  malady  which  I  mean  to  describe ; 
and  it  has  repeatedly  returned  at  irregular  periods,  from  that  to  the 

^  From  paj;,  litrht,  and  £i4«,  ■vision.     Visus  Lucidus.     Mx^iU^guj^a  of  Hippocrates, 
t  See  pages  139,  320,  and  388. 


615 

present  time.  The  first  notice  that  I  have  of  the  attack,  is  a  pe- 
cuUar  indescribable  sensation  at  the  bottom  of  the  eye,  which  does 
not  amount  to  pain,  and  is  so  shght  that  its  reahty  is  not  to  be 
determined,  unless  I  direct  my  attention  very  particularly  to  it. 
After  a  few  seconds  the  objects,  in  a  small  point,  nearly  in  the 
centre  of  the  field  of  vision,  become  indistinct ;  and,  shortly  after- 
wards, invisible.  ***** 
In  a  few  seconds  more,  that  is,  in  about  half  a  minute  from  the 
commencement  of  the  attack,  the  point  that  was  invisible  becomes 
lucid,  appearing  to  be  a  circular  spot,  about  the  eighth  of  an  inch 
in  diameter,  in  which  a  yellow  flame  seems  to  undulate  from  the 
centre  to  the  circumference  with  almost  coruscating  quickness  and 
splendour.  This  spot  increases  by  the  extension  of  the  undulating 
flame  until  it  acquires  an  apparent  diameter  of  about  three  quarters 
of  an  inch,  which  takes  place  generally  in  about  six  or  eight 
minutes.  The  fiery  veil,  which  conceals  objects,  becomes  then 
thinner  in  the  centre,  and  objects  are  there  seen  through  it.  The 
vision  increases,  until  at  length  a  ring  of  light  only  remains,  which 
continues  to  enlarge  until  it  is  lost  by  seeming  to  extend  beyond 
the  field  of  vision. 

"  The  returns  of  the  attack  have  been  very  irregular.  Some- 
times the)^  have  occurred  daily  for  a  week  or  ten  days  together ; 
at  other  times  more  than  a  month  has  elapsed  between  their  ap- 
pearance. During  one  forenoon  they  returned  almost  every  half 
hour ;  but  of  late  the  intervals  are  much  lengthened ;  and  I  have 
been  now  exempted  from  the  malady  more  than  three  months. 

"  At  first  no  pain  was  felt ;  but  during  the  last  twelve  months, 
a  slight  uneasiness  under  the  forehead,  on  the  opposite  side  to  that 
of  the  affected  eye,  has  generally  accompanied  and  succeeded  the 
attack. 

"  The  disease  is  common  to  both  eyes,  though  it  has  never 
yet  occured  in  both  at  the  same  time.  My  sight  is  not  injured, 
though  the  sensibility  of  the  retina  appears  to  be  morbidly  increased  : 
a  strongly  illuminated  object  producing  a  more  brilliant  spectrum 
than  it  used  to  do. 

"  About  six  weeks  ago  I  first  saw  the  unpleasing  appearance  of 
a  small  dark  circular  spot,  which,  varying  its  situation  with  every 
motion  of  the  eye,  showed  how  appropriately  the  term  musca  voli- 
tans  had  been  applied  to  it.  The  possibility  of  its  being  a  partial 
paralytic  affection,  resulting  from  the  frequent  morbidly  increased 
action  of  the  retina,  naturally  alarmed  me ;  but  six  weeks  having 
elapsed  without  any  return,  I  am  become  easy  concerning  it.  In 
this  instance  the  immediate  cause  of  the  affection  appears  to  have 
been  an  irregularly  increased  action  of  the  retina  ;  and  the  remote 
causes  were  an  over  eager  exercise  of  the  mind,  joined  with  too  long 
continued  employment  of  the  eyes,  and  a  disordered  state  of  the 
stomach  and  bowels. 


616 

"■  With  regard  to  the  means  of  curC;  reprehensible  as  it  may  ap- 
pear. I  for  a  long  time  employed  none.  About  three  years  ago^ 
however,  having  been  harassed  repeatedly  at  short  intervals,  and 
sometimes  two  or  three  times  in  the  day^.  by  the  above-mentioned 
appearances,  I  called  on  you,  and,  by  your  advice,  took  a  dose  of  five 
grains  of  calomel.  After  this  the  spectrum  did  not  appear  for  sev- 
eral months  ;  and  when  I  again  saw  it,  it  yielded  to  a  repetition 
of  the  same  remedy.  In  the  following  year,  having  travelled  two 
days  together,  and  taken  food  of  an  improper  kind,  and  in  an  irreg- 
ular manner,-  the  attacks  oa  the  third  morning  were  so  frequentl)^ 
repeated,  that  I  \vas  unable  to  see  my  way  without  difiiculty  and 
danger.  I  tbeiefore  stopped  and  took  my  dose  of  calomel ;  after 
which  the  spectrum  immediately  disappeared,  and  it  did  not  return 
for  many  months.  That  w^hfch  was  black  as  well  as  those  which 
were  lucid,  were  equally  removed  by  the  use  of  this  medicine  ;  antJ 
1  have  not  now  perceived  either  of  them  for  a  considerable  length 
of  time."  * 


SECTION  VI. OCULAR  SPECTRA,  OR  ACCIDENTAL  COLOURS. 

A  very  short  notice  of  this  class  of  phenomena  will  not,  I 
think,  appear  improper,  if  we  consider  that  they  are  the  result  of 
fatigue  of  the  eye,  and  that  fatigue  is  not  only  in  itself  a  disease, 
but  is  often  the  prelude  to  other  diseases  of  more  permanent  char- 
acter. 

When  one  has  long  and  attentively  looked  at  a  bright  object,  as 
at  the  setting  sun,  on  closing  his  eyes,  or  remo\nng  them,  an  image,, 
which  resembles  in  form,  the  object  he  was  attending  to,  continues 
for  some  time  to  be  visible.  This  appearance  is  called  the  ocular 
spectrum  of  the  object  \  and  as  it  is  often  of  a  colour  diSerent  from 
that  of  the  object  which  has  produced  it,  Buffon  gave  to  the  colours 
which  arise  in  this  way^  from  the  continued  action  of  light  upon 
the  retina,  the  name  of  accidental  colours,  in  order  to  distinguish 
them  from  those  which  are  produced  by  the  decomposition  of  white-, 
hght. 

Dr.  R.  W.  Darwin,  of  Shrewsbury,!  considers  ocular  spectra  un- 
der four  heads.  To  understand  his  views  of  this  subject,  it  is  ne- 
cessary to  know  that  he  regards  the  retina  as  a  fibrous  substance^ 
capable  of  a  certain  sort  of  activity,  which  produces  vision,  and  ca- 
pable even  of  spasmodic  or  irregular  action. 

I.  The  retina  is  not  so  easily  excited  into  action  by  a  less  irri- 
tation, after  having  been  lately  subjected  to  a  greater  ;  and  hence 
a  class  of  ocular  spectra  from  defect  of  sensibility,  as  in  the 
simple  experiment  just  referred  to.  Certain  of  the  muscoi  voli- 
tantes,  complained  of  by  people  of  delicate  constitutions,  when  their 

*  Medico-Chirur^cal  Transactions,  Vol.  v.  p.  274.     London,  1814. 
+  Philosophical  Transactions,  Vol.  Ixxvi.  p.  313.     London,  1786. 


617 

eyes  are  a  little  weakened  by  fatigue,  are  probably  ocular  spectra  of 
this  kind. 

II.  The  retina  is  more  easily  excited  into  action  by  a  greater  irrita- 
tion after  having  been  lately  subjected  to  a  less :  and  hence  a  class 
of  ocular  spectra  from  excess  of  sensibility,  as  in  the  following 
experiment.  Make  with  ink  on  white  paper  a  very  black  spot, 
about  half  an  inch  in  diameter,  with  a  tail  to  it  about  an  inch  long, 
so  as  to  represent  a  tadpole ;  look  steadily  for  a  minute  on  this  spot, 
and,  on  moving  the  eye  a  little,  the  figure  of  the  tadpole  will  be 
seen  on  the  white  part  of  the  paper,  whiter  or  more  luminous  than 
the  other  parts  of  the  paper.  The  part  of  the  retina  which  was  ex- 
posed to  the  black  spot,  is  now  more  sensible  to  light  than  the  other 
parts  of  it,  which  were  exposed  to  the  white  paper.  Dr.  Darwin 
regards  this  as  put  beyond  a  doubt  by  the  following  experiment. 
On  closing  the  eyes  after  viewing  the  black  spot  on  the  white  pa- 
per, a  red  spot  is  seen  of  the  form  of  the  black  spot :  for  that  part 
of  the  retina,  on  which  the  black  spot  was  dehneated,  being  now 
more  sensible  to  light  than  the  other  parts  of  it,  which  were  exposed 
to  the  white  paper,  is  capable  of  perceiving  the  red  rays  which  pen- 
etrate the  eyelids. 

III.  There  is  a  set  of  ocular  spectra,  which  resemble  their  ob- 
ject in  its  colour  as  well  as  form.  These  Dr.  Darwin  terms  direct 
ocular  spectra. 

If,  in  the  night,  we  place  the  bright  flame  of  a  spermaceti  can- 
dle before  a  black  object,  look  steadily  at  it  for  a  short  time,  till 
it  is  observed  to  become  somewhat  paler,  and  then  close  the  eyes, 
and  cover  them  carefully,  but  not  so  as  to  compress  them,  the 
image  of  the  blazing  candle  will  continue  distinctly  visible.  In 
this  case,  according  to  Dr.  Darwin,  a  quantity  of  stimulus  some- 
what greater  than  natural  excites  the  retina  into  spasmodic  action, 
which  ceases  in  a  few  seconds. 

If  we  place  a  spermaceti  candle  in  the  night  about  one  foot  from 
the  eye,  and  look  steadily  on  the  centre  of  the  flame,  till  the  eye 
becomes  much  more  fatigued  than  in  the  last  experiment ;  on  clos- 
ing the  eyes  a  reddish  spectrum  will  be  perceived,  which  will  re- 
peatedly cease  and  return.  In  this  case,  a  quantity  of  stimulus 
somewhat  greater  than  the  former  excites  the  retina  into  spasmod- 
ic action,  which  ceases  and  recurs  alternately. 

IV.  There  is  a  set  of  ocular  spectra,  of  a  colour  contrary  to  that 
of  their  object.  These  may  be  called  reverse  ocular  spectra. 
They  are  excited  by  a  stimulus  somewhat  greater  than  what  is 
sufficient  to  produce  the  direct  spectra,  and  are  supposed  by  Dr. 
Darwin  to  depend  on  the  retina  falUng  into  an  opposite  spasmodic 
action  to  that  which  had  previously  existed. 

If  we  place  a  piece  of  coloured  silk,  about  an  inch  in  diameter, 
on  a  sheet  of  white  paper,  and  about  half  a  yard  from  the  eyes, 
look  steadily  upon  it  for  a  minute,  then  remove  the  eyes  to  another 
part  of  the  paper,  a  spectrum  will  be  seen  of  the  form  of  the  silk, 

78 


618 

but  of  a  colour  opposite  it.  Red  silk  will  produce  a  green  spec- 
trum, green  a  red  one,  orange  blue,  blue  orange,  yellow  violet, 
and  violet  yellow.  These  reverse  spectra  are  similar  to  a  colour, 
formed  by  the  combination  of  all  the  primary  colours,  except  that 
with  which  the  eye  has  been  fatigued  in  making  the  experiment. 

In  contemplating  any  of  these  reverse  spectra  with  the  eye 
closed  and  covered,  it  disappears  and  re-appears  several  times  suc- 
cessively, till  at  length  it  entirely  vanishes,  hke  the  direct  spectra ; 
but  with  this  additional  circumstance,  that  when  the  spectrum  be- 
comes faint  or  evanescent,  it  is  instantly  revived  by  removing  the 
hand  from  before  the  eyelids,  so  as  to  admit  more  light.  The  ret- 
ina, being  still  sensible  to  all  other  rays  of  light,  except  that  with 
which  it  was  lately  fatigued,  is  stimulated,  by  the  admission  of 
these  rays,  into  those  motions  which  form  the  reverse  spectrum. 

If  the  retina  is  excited  by  a  stimulus  greater  than  the  last  men- 
tioned, it  falls  into  various  successive  spasmodic  actions.  Thus 
De  la  Hire  observed,  that  after  looking  at  the  bright  sun,  the  im- 
pression in  his  eye  first  assumed  a  yellow  appearance,  then  green, 
and  then  blue. 

Excited  by  a  still  greater  stimulus,  the  retina  may  fall  into  a 
fixed  spasmodic  action,  which  may  continue  for  some  days.  Thus 
Dr.  Darwin  found,  that  after  having  looked  long  at  the  meridian 
sun,  till  the  disc  faded  into  a  pale  blue,  he  frequently  observed  a 
bright  blue  spectrum  of  the  sun  on  other  objects  all  the  next  and 
succeeding  day,  which  constantly  occurred  when  he  attended  to 
it,  and  frequently  when  he  did  not  previously  attend  to  it. 

A  quantity  of  stimulus  greater  than  the  preceding  induces  a 
temporary  paralysis  of  the  organ  of  vision.  Place  a  circular  piece 
of  bright  red  silk,  about  half  an  inch  in  diameter,  on  the  middle 
of  a  sheet  of  white  paper ;  lay  them  on  the  floor  in  a  bright  sun- 
shine, and  fixing  the  eyes  steadily  on  the  centre  of  the  red  circle, 
for  three  or  four  minutes,  at  the  distance  of  four  or  six  feet  from 
the  object,  the  red  silk  will  gradually  become  paler,  and  finally 
cease  to  appear  red  at  all. 

The  following  miscellaneous  facts  regarding  ocular  spectra  ap- 
pear worthy  of  notice.  The  full  iEustration  of  them  will  be  found 
chiefly  in  Dr.  Darwin's  paper  ;  and  the  reader  may  farther  con- 
sult, on  this  subject,  the  works  mentioned  below.* 

1.  Though  a  certain  quantity  of  Hght  facilitates  the  formation  of 
the  reverse  spectrum,  a  greater  quantity  prevents  its  formation,  as 
the  more  powerful  stimulus  excites  even  the  fatigued  parts  of  the 
eye  into  action ;  otherwise  we  should  see  the  spectrum  of  the  last 
viewed  object  as  often  as  we  turn  our  eyes. 

*  De  la  Hire  sur  les  differens  Accidens  de  la  Vue,  1694. — Jurin's  Essay  on  Distinct 
and  Indistinct  Vision,  at  the  end  of  Smith's  Optics — Buffon  sur  les  Couleurs  Acci- 
dentelles,  Memoires  de  I'Academie  Royale  des  Sciences,  1743. — Porterfield  on  the  Eye, 
Vol.  i.  p.  343. — ^pinus,  Novi  Comment.  Petrop.  Tom.  x. — Memoires  de  I'Acad. 
de  Berlin,  1771. — Hauy's  Traite  de  Physique. — Rozier's  Observations  sur  la  Physique, 
Tom.  xxvi.  pp.  175,  273,  291. — Article,  Accidental  Colours,  in  the  Edinburgh  Ency- 
clopsdia. 


619 

2.  When  a  direct  spectrum  is  thrown  on  colours  darker  than 
itself,  it  mixes  with  them  ;  as  the  yellow  spectrum  of  the  setting 
sun,  thrown  on  the  green  grass,  becomes  a  greener  yellow.  But 
when  a  direct  spectrum  is  thrown  on  colours  brighter  than  itself,  it 
becomes  instantly  changed  into  the  reverse  spectrum,  which  mixes 
with  those  brighter  colours.  So  the  yellow  spectrum  of  the  setting 
sun  thrown  on  the  luminous  sky  becomes  blue,  and  changes  with 
the  colour  or  brightness  of  the  clouds  on  which  it  appears.  But 
the  reverse  spectrum  mixes  with  every  kind  of  colour  on  which  it 
is  thrown,  whether  brighter  than  itself  or  not :  thus,  the  reverse 
spectrum,  obtained  by  viewing  a  piec^  of  yellow  silk,  when  thrown 
on  white  paper,  is  a  lucid  blue  green  ;  when  thrown  on  black  Tur- 
key leather,  it  becomes  a  deep  violet.  In  these  cases  the  retina  is 
thrown  into  activity  or  sensation  by  the  stimulus  of  external  colours, 
at  the  same  time  that  it  continues  the  activity  or  sensation  which 
forms  the  spectra. 

3.  All  experiments  upon  ocular  spectra  are  apt  to  be  confounded, 
if  they  are  made  too  soon  after  each  other,  as  the  remaining  spec- 
trum will  mix  up  with  the  new  ones.  This  is  a  very  troublesome 
circumstance  to  painters,  who  are  obliged  to  look  long  upon  the 
same  colour ;  and  in  particular  to  those  whose  eyes,  from  natural 
debihty,  cannot  long  continue  the  same  kind  of  exertion. 

4.  From  some  occasional  phenomena  observed  in  experimenting 
on  the  subject  of  ocular  spectra,  it  would  appear  that  an  impression 
on  the  one  retina  can  be  conveyed  to  the  other.  Thus,  Dr.  Brews- 
ter taking  advantage  of  a  fine  summer's  day,  when  the  sun  was 
near  the  meridian,  formed  a  very  brilliant  and  distinct  image  of  his 
disc,  by  means  of  the  concave  mirror  of  a  reflecting  telescope.  His 
right  eye  being  tied  up,  he  viewed  this  luminous  disc  with  the  left 
through  a  tube,  which  prevented  any  extraneous  light  from  falling 
upon  the  retina.  When  the  retina  was  highly  excited  by  the 
solar  image,  he  turned  his  left  eye  to  a  while  ground,  and  examined 
the  series  of  ocular  spectra  which  followed.  After  uncovering  his 
right  eye,  a  remarkable  phenomenon  appeared  ;  for  on  turning  it 
on  a  white  ground,  he  found  that  it  also  gave  a  coloured  spectrum. 
He  repeated  the  experiment  twice,  in  order  to  be  secure  against  de- 
ception, and  always  with  the  same  result.  The  spectrum  in  the 
left  eye  was  uniformly  invigorated  by  closing  the  eyelids,  because 
the  images  of  external  objects  efface  the  impression  upon  the  retina; 
and  when  he  refreshed  the  spectrum  in  the  left  eye,  that  in  the 
right  was  also  strengthened.  On  repeating  this  experiment  a  third 
time,  the  spectrum  appeared  in  both  eyes,  which  seems  to  prove, 
that  the  impression  of  the  solar  image  was  conveyed  by  the  optic 
nerve  from  the  left  to  the  right  eye  ;  for  the  right  eye  being  shut, 
could  not  be  affected  by  the  luminous  image.* 

5.  Ocular  spectra  sometimes  continue  for  days  or  weeks,  and 

*  Article,  Accidental  Colours,  in  the  Edinburgh  Encyclopedia. 


620 

are  often  followed  in  such  cases  by  serious  affections  of  the  retina. 
Thus,  Dr.  Brewster  found,  after  the  experiments  just  quoted,  that 
his  eyes  were  reduced  to  such  a  state  of  extreme  debility,  that  they 
were  unfit  for  any  farther  trials.  A  spectrum  of  a  darkish  hue 
floated  before  his  left  eye  for  many  hours,  succeeded  by  the  most 
excruciating  pains,  shooting  through  every  part  of  the  head.  These 
pains,  accompanied  with  a  shght  inflammation  in  both  eyes,  lasted 
for  several  days.  Two  years  after,  the  debility  of  the  eyes  still 
continued,  and  several  parts  of  the  retina  in  both  eyes  had  com- 
pletely lost  their  sensibihty.* 

Buffon  tells  us,  that  one  of  his  friends  having  one  day  looked  at 
an  eclipse  of  the  sun  through  a  small  hole,  observed  for  more  than 
three  weeks  a  coloured  image  of  that  body  upon  all  objects.  When 
he  fixed  his  eyes  upon  a  brilliant  yellow,  as  that  of  a  gilt  frame, 
he  saw  a  purple  spot ;  when  on  blue,  as  that  of  a  slated  roof,  a 
green  spot.t  Buffon  himself  brought  on  muscce,  volitantes  by  his 
experiments  on  accidental  colours. 

In  the  mouth  of  July,  a  lady  of  advanced  age,  went  from  Lon- 
don to  the  eastern  coast  of  Kent,  where  she  lodged  in  a  house  look- 
ing immediately  upon  the  sea,  and  of  course  very  much  exposed  to 
the  glare  of  the  morning  sun.  The  curtains  of  the  bed  in  which 
she  slept,  and  also  of  the  windows,  were  of  white  linen,  which 
made  her  apartment  very  light.  When  she  had  been  there  about 
ten  days,  she  observed,  one  evening,  at  the  time  of  sunset,  that 
first  the  fringes  of  the  clouds  appeared  red,  and  soon  after  the  same 
colour  was  diffused  over  all  the  objects  around  her.  It  was  par- 
ticularly conspicuous  when  she  regarded  any  thing  white,  as  a 
sheet  of  paper,  a  pack  of  cards,  or  a  lady's  gown.  This  lasted  the 
whole  night.  The  next  morning  her  sight  was  perfectly  restored. 
But  as  the  evening  advanced,  the  same  appearances  came  on 
again ;  and  they  continued  to  do  so  regularly  every  evening,  as 
long  as  she  remained  at  that  place,  which  was  three  weeks  from 
the  commencement  of  her  complaint :  the  natural  vision  always 
returning  in  the  morning. 

Six  days  after  she  had  left  the  coast,  Dr.  Heberden  saw  her  in 
London,  still  subject  to  the  same  affection.  It  persevered  a  fort- 
night longer,  and  then,  of  its  own  accord,  ceased  suddenly  and 
entirely.  While  it  was  upon  her,  the  sight  seemed  to  be  no  other- 
wise impaired  than  by  the  degree  of  indistinctness  necessarily  pro- 
duced by  this  unnatural  colour,  which  overspread  all  her  view. 
There  seems  every  reason  to  suppose  that  this  lady's  complaint 
was  brought  on  by  her  being  exposed  to  an  unusual  glare  of  light, 
and  that  it  partook  more  of  the  nature  of  an  ocular  spectrum  than 
of  any  thing  else.t 

.    *  Article,  Accidental  Colours,  in  the  Edinburgh  Encyclopaedia. 

t  Memoiies  de  I'Academie  Royale  des  Sciences,  Annee  1743,  page  214.  Amster- 
dam, 1748.  See  Larrey's  Recueil  de  Memoires  de  Chirurgie,  p.  227,  for  two  cases  of 
Amaurosis  from  viewing  an  eclipse  of  the  sun. 

t  Medical  Transactions  of  the  College  of  Physicians.  Vol.  iv.  p.  S&.  London, 
1813. 


621 

6,  There  must  at  all  times,  and  from  every  object,  be  a  ten- 
clency  to  the  production  of  ocular  spectra  ;  but  partly  from  habitual 
want  of  attention  to  them,  partly  from  their  being  effaced  in  the 
overwhelming  effect  of  direct  impressions,  they  are  seldom  mad'C 
the  subject  of  complaint,  except  by  those  whose  eyes  are  peculiarly 
sensible,  or  have  become  greatly  weakened  by  over-fatigue  and 
other  causes.  la  such  persons  a  mixture  of  photopsia,  muscae 
volitantes,  and  ocular  spectra,  is  not  uncommon.  There  are  few, 
however,  who,  after  retiring  from  the  toils  of  the  day,  have  not,  at 
one  time  or  another,  been  sensible,  on  shutting  their  eyes  where 
only  a  very  moderate  quantity  of  light  was  present,  of  an  impres- 
sion as  if  from  myriads  of  minute  figures,  of  various  colours,  ap- 
pearing in  constant  motion,  and  assuming  an  endless  succession  of 
different  arrangements,  I  presume  that  this  sensation  must  iri 
general  be  referred  to  the  class  of  ocular  spectra,  and  be  regarded 
as  the  effect  of  the  infinite  variety  of  impressions  made  upoti  the 
retina  through  the  course  of  the  day. 


SECTION  VH. MUSC^  VOLITANTES. 

Various  false  visual  sensations  have  been  described  under  the 
name  of  muscce  volitantes.  The  name  denotes  that  in  general 
they  bear  a  resemblance  to  flies  moving  through  the  air  ;  but  the 
objects  to  which  they  are  more  particularly  compared,  by  those 
who  are  the  subjects  of  them,  and  the  descriptions  which  are  given 
of  their  figure,  size,  and  degree  of  opacity,  are  widely  different ; 
as  are  also  the  pictorial  representations  which  are  often  made  of 
them  on  paper. 

One  set  of  muscse  volitantes  are  semitransparent,  and  although 
when  carelessly  described,  they  are  said  to  resemble  mist,  or  a 
shower  of  minute  drops,  yet  when  attentively  examined  by  the 
patient,  he  generally  finds  that  they  present  an  appearance  of 
minute  twisted  tubes,  partially  filled  with  globules,  which  some- 
times appear  in  motion.  Another  set  are  more  opaque  or  perfectly 
dark,  and  are  therefore  spoken  of  as  black  spots,  which  follow  the 
motions  of  the  eye,  and  partially  cover  every  object  to  which  the 
patient  turns  his  attention, 

I  have  been  led  to  suspect  that  these  two  sets  of  muscee  volitantes 
are  specifically  distinct ;  and  that  the  latter  are  of  a  more  dangerous 
character  than  the  former.  The  black  spot,  or  spots,  whether  com- 
pared to  a  flake  of  black  wool,  to  the  body  of  a  spider,  with  perhaps 
three  or  four  diverging  legs^  or  to  whatever  else,  is  not  unfrequently 
the  precursor  of  amaurosis  :  while  the  semitransparent  spectra  prove, 
in  many  instances,  troublesome  for  ten,  or  even  twenty  years  to- 
gether, and  yet  end  in  nothing  seriously  affecting  vision.  It  is 
necessary,  however,  to  mention  that  the  dark  muscae  volitantes  are 
not  to  be  regarded  as  uniformly  of  a  dangerous  character ;  for  like 


622 

the  semitransparent,  they  sometimes  continue  unchanged  for  many 
years,  while  in  other  instances,  they  are  gradually  dissipated,  and 
at  length  totally  removed. 

Muscfe  volitantes  seldom  appear  in  the  optic  axis,  but  are  gen- 
erally  to  one  or  other  side  of  it,  or  above  it,  or  below.  Hence  it  is 
that  the  individual  observes  them  only  by  the  by;  at  first,  he  is 
led  to  suppose  that  some  sooty  filament,  or  particle  of  dust  is  chng- 
ing  to  his  eyelids,  which  he  endeavours  to  brush  away  with  his 
hand ;  for  a  day  or  two,  perhaps,  the  sensation  does  not  trouble 
him,  and  then  it  returns ;  w^hen  he  endeavours  to  examine  with 
more  exactness  the  form  and  appearance  of  what  seems  flitting 
before  him,  he  finds  from  its  obliquity  that  it  is  difiicult  to  do  so ; 
and  when  be  turns  his  eye,  as  if  to  fix  it  in  the  axis  of  vision,  it 
seems  suddenly  to  fly  from  before  him.  If  it  happens,  however, 
to  be  situated  more  in  the  direction  of  the  centre  of  the  retina,  the 
patient  finds  that  he  can  bring  it  directly  before  him  for  examina- 
tion, and  that  viewed  upon  a  sheet  of  paper  at  the  usual  distance 
for  distinct  vision,  it  appears  less  in  size,  and  more  defined,  than 
when  he  brings  it  upon  a  distant  wall,  or  carries  it  to  the  sky. 

Patients  are  often  persuaded  that  muscse  volitantes  move,  and 
will  not  readily  be  convinced  that  this  is  a  mere  deception.  They 
will  sometimes  tell  us,  for  instance,  that  when  they  raise  their  eyes 
rather  quickly,  the  muscee  volitantes  fly  upwards,  but  if  they  fix 
their  sight  upon  a  cloud  or  other  elevated  object,  that  they  descend 
slowly,  as  if  towards  the  bottom  of  the  eye  ;  that  they  do  not  see 
them  when  they  continue  to  look  steadily  at  the  same  object ;  but 
that  on  the  least  motion  of  the  eyes,  the  muscae  leave  the  situation 
which  from  their  gravity  they  had  assumed,  and  come  again  into 
view.  Now,  all  these  motions  are  merely  apparent.  In  those 
muscae,  indeed,  which  present  the  appearance  of  globules  contained 
within  semitransparent  tubes,  there  is  sometimes  perceived  a  motion 
which  is  real,  and  which  is  probably  that  of  the  blood  passing 
through  the  vessels  of  the  retina,  or  of  the  vitreous  humour :  but 
neither  these  semitransparent  tubes  themselves,  nor  any  of  the  fila- 
mentous muscse,  or  black  spots,  which  are  so  frequently  complained 
of,  possess  any  real  motion,  independent  of  the  general  motion  of 
the  eyeball.  If  the  cause  of  the  muscce  volitantes.  be  it  in  the  vit- 
reous humour,  or  in  the  retina,  lies  below  the  optic  axis,  it  will  pro- 
duce an  impression  as  if  it  were  placed  above  the  level  of  the  eye, 
inducing  us  to  turn  our  eyes  that  way,  expecting  to  bring  it  into 
the  centre  of  the  eye,  that  we  may  view  it  more  distinctly  ;  and 
in  this  case  the  dark  spots  seem  to  fly  upwards.  Slowly  as  the 
eyes  descend,  the  muscse  again  come  into  view.  If  the  cause  hes 
above  the  optic  axis,  we  pursue  it  from  the  same  motive,  and  it 
seems  to  move  downwards.  If  the  cause  be  placed  much  to  one 
side  of  the  optic  axis,  be  it  above  or  below,  to  the  right  or  to  the 
left,  it  is  impossible  to  gain  a  deliberate  view  of  the  spectrum  which 
it  produces.     It  flies,  as  it  were,  before  us,  and  as  quickly  returns 


623 

again  to  annoy  the  eye,  equally  tired  of  its  presence  and  of  the  in- 
effectual attempis  made  to  examine  it  more  at  leisure.  But  if  the 
cause  be  within  a  few  degrees  of  the  optic  axis,  no  difficulty  is  ex- 
perienced in  obtaining  a  distinct  view  of  the  musca.  The  patient 
brings  it  at  once  on  the  paper,  and  with  his  pen  delineates  its  form 
for  the  information  of  others. 

Proximate  causes.  Muscee  volitantes  are  never  seen,  in  the 
sense  that  objects  out  of  the  eye  are  seen.  Opaque  spots,  in  any 
part  of  the  eye  anterior  to  the  retina,  could  never  produce  an  im- 
age on  that  membrane,  sufficiently  defined  to  give  rise  to  such  im- 
pressions as  the  generality  of  muscse  volitantes.  Such  spots  might 
produce  an  obscurity  in  vision,  by  intercepting  a  certain  number  of 
the  rays  of  light,  exactly  as  specks  on  the  cornea,  depositions  in 
the  pupil,  or  incipient  cataract  does,  or  as  any  one  may  do  by  hold- 
ing an  opaque  body,  such  as  a  piece  of  wire  or  a  common  probe, 
across  and  close  to  his  cornea  ;  but  no  object  within  the  eye,  (nor 
indeed  without  the  eye,  unless  beyond  a  certain  distance  from  the 
cornea,)  can  be  brought  to  a  focus  on  the  retina,  or  produce  any 
other  impression  than  a  greater  or  less  degree  of  dimness.  This, 
however,  is  evidently  not  at  all  the  kind  of  impression  produced  in 
what  we  term  muscee  volitantes.  Even  when  these  appearances 
are  remote  from  the  axis  of  vision,  so  that  they  cannot  be  dwelt 
upon,  but  are  only  glanced  at,  as  if  in  passing,  they  are  still  too 
much  defined,  to  be  of  the  nature  of  mere  shadows,  arising  from 
intercepted  light. 

I  by  no  means  deny  that  the  branches  of  the  arteria  centralis 
retinae,  which  ramify  through  the  hyaloid  membrane,  and  end  on 
the  posterior  hemisphere  of  the  crystaUine  capsule,  are  capable  of 
becoming  varicose;  that  opaque  depositions  may  take  place  in  the 
lens  ;  or  opaque  corpuscules  float  in  the  aqueous  humour  ;  but  as 
these  cannot  cause  muscse  vohtantes,  this  disease  must  be  referred 
either  to  the  retina  itself,  including  of  course  the  three  laminae  of 
which  it  is  composed,  or  to  the  choroid  coat.  The  probability  is, 
that  the  semitransparent  muscse  of  tubular  form  are  owing  to  a 
dilatation  of  the  branches  of  the  arteria  centrahs  retinae,  and  that 
the  dark  muscae  are  the  effects  of  certain  portions  of  the  retina  hav- 
ing become  altogether  insensible  to  light,  either  from  the  pressure 
of  some  irregular  projecting  point  or  points  of  the  choroid,  or  from 
some  other  cause.  We  can  conceive  the  nervous  layer  of  the  retina 
to  be  in  one  or  in  many  minute  portions  of  its  extent  so  altered 
by  disease,  or  so  pressed  upon  by  the  neighbouring  parts  in  a  mor- 
bid state,  as  to  be  no  longer  capable  of  being  stimulated  by  light 
at  the  parts  affected,  each  of  which  will  necessarily  give  rise  to  the 
sensation  of  a  musca  volitans.  Blood  effused  either  by  fhe  vessels 
of  the  retina,  or  those  of  the  choroid,  is  a  likely  cause  of  partial  in- 
sensibility of  the  retina,  and  consequently  of  muscae  volitantes. 

Remote  Causes.     A  very  proper  distinction  has  been  made  be- 
tween those  muscae  volitantes  which  appear  to  depend  on  plethora 


624 

aiid  sanguinous  congestion,  and  those  which  are  coonected  with 
atony  and  general  weakness.  The  former  are  apt  to  follow  or  tc 
be  combined  with  photopsia,  and  may  be  caused  by  whatever  pro- 
duces an  increased  supply  of  blood  to  the  head  and  eyes,  or  im- 
pedes its  return.  The  latter  are  among  the  most  frequent  effects- 
of  disordered  digestion,  arising  from  want  of  exercise,  and  of  a  long 
continuance  of  any  of  the  depressing  passions. 

Prognosis.  Few  symptoms  prove  so  alarming  to  persons  of  a 
nervous  habit  or  constitution  as  muscse  volitantes.  They  immedi- 
ately suppose  that  they  are  about  to  lose  their  sight,  by  cataract  or 
amaurosis.  We  may  safely  assure  them  that  there  is  no  danger 
of  either  of  these  terminations,  unless  other  symptoms  be  present.- 
These  false  perceptions  do  not  render  objects  obscure,  as  incipient 
cataract  doe&  ^  nor  is  there  any  fixedness  or  even  unnatural  slow- 
ness of  the  iris,  in  simple  cases  of  muscse  volitantes. 

Trecetment.  When  this  disease  is  evidently  connected  with 
sanguinous  turgescence,  there  can  be  no  doubt  of  the  propriety  of 
depletory  treatment ;  but  in  by  far  the  greater  number  of  instances^ 
an  opposite  plan  requires  to  be  followed,  for  in  the  weakly  or  ner- 
vous persons,  who  in  nine  cases  out  of  ten  form  the  subjects  of 
muscse  volitantes,  debilitating  remedies  will  not  only  afford  no  as- 
sistance, but  even  aggravate  the  symptoms.  The  mind  must  be 
relieved  as  much  as  possible  from  intense  application  of  every  kind^ 
and  the  patient  assured,  not  only  of  the  absence  of  all  danger  to 
the  sight,  if  the  muscse  volitantes  appear  to  be  uncombined  with 
other  symptoms,  but  of  the  probability  of  these  false  perceptions  be- 
coming less  and  less  troublesome,  in  proportion  as  the  strength  and 
spirits  are  recruited. 

The  state  of  the  bowels  must  in  every  instance  be  attended  to ; 
as  these  are  often  sluggish  in  their  action,  and  the  secretion  of  bile 
faulty  OF  defective.  In  such  cases,  purgatives  will  be  found  high- 
ly advantageous  ;  and  ought  to  be  followed  by  a  course  of  tonics,- 
such  as  the  precipitated  carbonate  of  iron,  the  sulphate  of  quina 
and  the  like.     Yalerian,  and  other  anti-spasmodics  are  also  useful. 

If  the  eyes  have  been  weakened  by  the  frequent  discharge  of 
tears,  it  will  be  useful  to  foment  them  v/ith  a  tepid  infusion  of 
chamomile  flowers^  twice  or  thrice  daily  f  and  afterwards  to  rub^ 
the  forehead^  temples,  and  outside  of  the  eyelids  with  emi  de  Co- 
logne, or  some  sk»ilar  apphcation. 


&ECTI©N  VIII. SPECTRAL  ILLUSIONS, 

The  phenomena  falling  under  this  head  may  be-  referred,  in- 
one  set  of  cases,  merely  to  the  insensibility  of  the  eye  to  direct  im- 
pressions of  very  faint  light ;  while  another  set  must  be  regarded 
as  symptoms  of  a  disorder  in  that  part  of  the  brain,  which  assists 
in  forming  the  optic  apparatus. 


625 

I.  Dr.  Brewster  observes,  that  when  the  eye  is  steadily  directed  to 
objects  illuminated  by  a  feeble  gleam  of  light,  it  is  thrown  into  a  state 
nearly  as  painful  as  that  which  is  produced  by  an  excess  of  light:  ^ 
A  kind  of  remission  takes  place  in  the  conveyance  of  the  impres- 
sions ;  the  object  actually  disappears,  and  the  eye  is  agitated  by 
the  recurrence  of  impressions  which  are  too  feeble  for  the  perform- 
ance of  its  functions. 

These  facts  "  may  serve,"  says  Dr.  Brewster,  "  to  explain  some 
of  those  phenomena  of  the  disappearance  and  reappearance  of  ob- 
jects, and  of  the  change  of  shape  of  inanimate  objects,  which  have 
been  ascribed  by  the  vulgar  to  supernatural  causes,  and  by  philoso- 
phers to  the  activity  of  the  imagination.  If  in  a  dark  night,  for 
example,  we  unexpectedly  obtain  a  glimpse  of  any  object,  either 
in  motion  or  at  rest,  we  are  naturally  anxious  to  ascertain  what  it 
is,  and  our  curiosity  calls  foith  all  our  powers  of  vision.  This 
anxiety,  however,  serves  only  to  baffle  us  in  our  attempts.  Ex- 
cited by  a  feeble  illumination,  the  retina  is  not  capable  of  affording 
a  permanent  vision  of  the  object,  and  while  we  are  straining  our 
eyes  to  discover  its  nature,  it  will  entirely  disappear,  and  afterwards 
reappear  and  vanish  alternately."" 

II.  An  excellent  account  of  spectral  illusions,  arising  from  dis- 
ease, has  been  published  by  Dr.  Hibbert,  under  the  title  of  Sketches 
of  the  Philosophy  of  Apparitions.  He  traces  them  to  a  great 
variety  of  causes ;  as,  highly-excited  states  of  particular  tempera- 
ments, hysteria,  hypochondriasis,  the  neglect  of  accustomed  periodi- 
cal blood-letting,  febrile  and  inflammatory  affections,  inflammation 
of  the  brain,  delirium  tremens  or  mania  a  potu,  &c. 

The  spectral  illusions,  described  by  those  troubled  with  this  dis- 
ease, are  infinitely  various ;  sometimes  bearing  the  appearance  of 
a  single  person  or  other  object,  and  in  the  other  cases,  imitating  the 
impression  which  might  be  produced  by  crowds  of  human  beings 
moving  before  the  spectator,  or  by  scenes  of  endless  diversity. 
Many  patients  affected  with  visions,  are  unable  to  distinguish  them 
from  real  iinpressions,  and  call  upon  the  spectators  to  look  at  the 
objects  of  their  terror  or  surprise  ;  others,  though  they  can  scarcely 
persuade  themselves  that  the  impressions  under  which  they  labour 
do  not  arise  from  real  objects,  feel  a  degree  of  diffidence  in  announc- 
ing what  they  see  to  the  bystanders,  whose  society  they  sometimes 
seek  only  in  order  to  dissipate  the  intruders  ;  while  a  third  set  are 
perfectly  conscious  from  first  to  last  that  they  are  labouring  under  a 
disease,  which  renders  them  the  subjects  of  false  perceptions.  The 
fact,  that  spectral  illusions,  in  some  instances,  have  been  attended 
by  fatal  effects,  has  been  particularly  mentioned  by  Hippocrates.f 

The  beneficial  influence  of  sleep,  procured  by  the  liberal  adminis- 
tration of  opiu  in,  in  banishing  the  phantasmsof  thoselabonring  under 

mania  a  potu,  is  well  known.     Other  sorts  of  remedies  will  be  re- 

t 

*  Edinburgh  Journal  of  Science,  Vol.  iii.  p.  209.     Edinburgh,  182,5. 
t  De  Natura  Muliebri. 

79 


626 

quired  in  other  ceises,  and  will  sometimes  operate  in  a  manner  almost 
equally  striking.  Witness  the  effects  of  depletion,  in  the  celebrated 
case  of  Nicolai,  the  Berlin  bookseller,  who  for  nearly  two  months 
was  constantly  affected  with  spectral  illusions. 

"  Though  at  this  time,"  says  he,  "  1  enjoyed  rather  a  good  state 
of  health  both  in  body  and  mind,  and  had  become  so  very  familliar 
with  these  phantasms,  that  at  last  they  did  not  excite  the  least  dis- 
agreeable emotion,  but  on  the  contrary  afforded  me  frequent  sub- 
jects for  amusement  and  mirth  ;  yet  as  the  disorder  sensibly  in- 
creased, and  the  figures  appeared  to  me  for  whole  days  together, 
and  even  during  the  night,  if  I  happened  to  wake,  I  had  recourse  to 
several  medicines,  and  was  at  last  again  obliged  to  have  recourse 
to  the  application  of  leeches  to  the  anus. 

"  This  was  performed  on  the  20th  of  April,  at  eleven  o'clock  in 
the  forenoon.  I  w^as  alone  with  the  surgeon,  but  during  the 
operation,  the  room  swarmed  with  human  forms  of  every  descrip- 
tion, which  crowded  fast  one  on  another ;  this  continued  till  half- 
past  four  o'clock,  exactly  the  time  when  the  digestion  commences. 
I  then  observed  that  the  figures  began  to  move  more  slowly  ;  soon 
afterwards  the  colours  became  gradually  paler ;  every  seven  min- 
utes they  lost  more  and  more  of  their  intensity,  without  any  altera- 
tion in  the  distinct  figure  of  the  apparitions.  At  about  half-past 
six  oclock,  all  the  figures  were  entirely  white,  and  moved  very  lit- 
tle ;  yet  the  forms  appeared  perfectly  distinct ;  by  degrees  they  be- 
came visibly  less  plain,  without  decreasing  in  number,  as  had  often 
formerly  been  the  case.  The  figures  did  not  move  off,  neither  did 
they  vanish,  which  also  had  usually  happened  on  other  occasions. 
In  this  instance  they  dissolved  immediately  into  air;  of  some,  even 
whole  pieces  remained  for  a  length  of  time,  which  also  by  degrees 
were  lost  to  the  eye.  At  about  eight  o'clock,  there  did  not  remain 
a  vestage  of  any  of  them,  and  I  have  never  since  experienced  any 
appearance  of  the  same  kind.  Twice  or  thrice  since  that  time,  I 
have  felt  a  propensity,  if  I  may  be  so  allowed  to  express  myself,  or 
a  sensation,  as  if  I  saw  something,  which  in  a  moment  again  was 
gone."  * 

Even  a  change  in  the  position  of  the  body,  such  as  may  possibly 
modify  the  state  of  the  circulation  through  the  brain,  has  sometimes 
been  known  to  dissipate  the  phantasms  produced  by  disordered  sen- 
sation. "  I  know  a  gentleman."  says  an  anonymous  writer  on  this 
subject,  "  at  present  in  the  prime  of  life,  who  in  my  opinion  is  not 
exceeded  by  any  one,  in  acquired  knowledge,  and  originality  of 
deep  research  ;  and  who,  for  nine  months  in  succession,  was  al- 
ways visited  by  a  figure  of  the  same  man,  threatening  to  destroy 
him,  at  the  time  of  going  to  rest.  It  appeared  upon  his  lying 
down,  and  instantly  disappeared  when  he  resumed  the  erect  pos- 
ture." t 

**  Nicolai's  Memoir,  in  Nicholson's  Journal,  Vol.  \i.  p.  IHl.     London,  1803. 
t  Nicholson's  Journal,  Vol.  xv.  p.  289<     London,  ISOti. 


627 

It  must  be  Irighl}^  beneficial  to  those  who  lubouv  under  such 
disordered  sensations,  to  be  made  acquainted  with  the  fact,  that  they 
arc  merely  the  subjects  of  a  peculiar  disease  of  the  internal  optic 
apparatus,  the  effect  of  which  is  to  produce  a  repetition  or  imitation 
of  former  impressions.  By  this  means  the  minds  of  those  may  be 
calmed,  who  otherwise  might  be  led  to  ascribe  their  visions  to  su- 
pernatural powers,  or  who  through  fear  or  terror  might  be  driven  to 
insanity.* 


SECTION    IX. NIGHT-BLINDNESS.t 

Case.  As  the  servant  to  a  corn-miller  was  employed,  one 
evening  near  sunset,  in  mending  some  sacks,  he  felt  himself  sud- 
denly deprived  of  the  use  of  his  hmbs,  and  of  his  sight.  At  the 
time  he  was  attacked  by  this  uncommon  disease,  he  was  not  only 
entirely  free  from  any  pain  in  his  head,  or  limbs,  but,  on  the  con- 
trary, had  a  sensation  of  ease  and  pleasure  ;  he  was,  as  he  expressed 
liimself,  as  if  in  a  pleasing  dose,  but  perfectly  sensible.  He  was 
immediately  carried  to  bed,  and  watched  till  midnight ;  at  which 
time  he  desired  those  who  attended  him,  to  leave  him,  because  he 
was  neither  sick,  nor  in  pain.  He  continued  the  whole  night 
totally  blind,  and  without  a  wink  of  sleep.  When  the  daylight 
of  the  next  morning  appeared,  his  sight  returned  to  him  gradually, 
as  the  light  of  the  sun  increased,  till  it  became  as  perfect  as  ever. 
When  he  rose  from  his  bed,  he  found  his  limbs  restored  to  their 
usual  strength  and  usefulness,  and  himself  in  perfect  health. 

But  on  the  evening  of  the  same  day,  about  sunset,  he  began  to  see 
but  obscurely,  his  sight  gradually  departed  from  him,  and  he  became 
as  blind  as  on  the  preceding  night ;  though  his  limbs  continued 
as  well  as  in  perfect  health,  nor  had  he  from  the  first  night  any 
farther  complaint  from  that  quarter.  Next  day,  with  the  rising 
sun,  his  sight  returned  ;  and  this  was  the  almost  constant  course  of 
the  disease,  for  two  months. 

The  symptoms,  which,  from  the  second  night,  constantly  pre- 
ceded the  blindness,  were  a  slight  pain  over  the  eyes,  and  a  noise 
in  his  head.  That  he  was  totally  bhnd  every  night,  when  these 
symptoms  appeared,  was  evident,  from  his  not  being  able  to  see  the 
light  of  a  candle,  though  held  close  to  his  eyes  ;  and  that  in  the 
day  his  sight  was  perfect,  was  as  manifest,  from' his  being  capable 
of  reading  the  smallest  print,  and  threading  the  finest  needle. 

*  The  reader  who  wishes  to  pursue  the  subject  of  Spectral  Illusions,  in  addition  to 
the  worlis  already  referred  to,  may  consult  the  following. — Cardanus  de  Vita  Propria. 
— Ferrier's  Theory  of  Apparitions. — Alderson,  in  Edinburgh  Medical  and  Surgical 
Journal,  Vol.  vi. — Armstrong,  in  Ibid.  Vol.  ix. — Simpson,  in  Phrenological  Journal, 
No.  6. — Edinburgh  Journal  of  Science  for  April,  1830. 

t  JVyctalopia  of  some,  and  hemeralopia  of  others,  terms  which  it  were  better  al- 
together to  avoid.  Nyctalopia  more  especially  has  been  used  to  signify  both  seeing  by 
night,  and  night  blindness.  Sometimes  even  the  same  author  uses  the  word  in  both 
opposite  D2eanings.  It  seems  doubtful  whether  it  is  a  compound  of  vufjand  a^f,  mere- 
ly, or  of  yu|,  *  primitive,  and  m^  j  and  a  similar  doubt  hangs  over  hemeralopia. 


628 

The  first  day  that  Dr.  Pye  saw  liis  patient,  he  found  his  eyes 
perfectly  natural,  but  some  time  after  he  observed  the  pupils,  during 
one  of  the  nocturnal  paroxysms,  to  be  enlarged  about  one-third  in 
diameter.  After  nearly  two  months'  continuance  of  the  disease,  it 
began  to  be  less  regular  in  its  occurrence,  the  patient  retaining 
his  sight  for  a  single  night  or  for  several  nights  together,  and 
then  the  blindness  recui'ring.  Dr.  Pye,  who  relates  the  case,* 
put  him  at  last  on  the  use  of  cinchona,  and  thought  it  successful  in 
removing  the  complaint.  It  must  be  observed,  however,  that  the 
patient,  while  taking  the  cinchona,  laboured  under  a  spontaneous 
diarrhoea,  in  consequence  of  which  he  became  gradually  weaker 
and  weaker.  His  sight  he  retained  from  the  first  day  after  using 
the  medicine,  but  ten  days  after,  we  find  him  delirious,  and  deprived 
of  hearing,  and,  in  five  days  more  he  died. 

I  have  quoted  this  case,  as  a  good  example  of  night-blindness, 
a  disease  which  though  rare  in  this  country,  is  by  no  means  un- 
frequent  in  warm  chmates,  and  to  which  seamen  appear  to  be  par- 
ticularly exposed. 

Symptoms.  The  first  attack  of  this  disease  generally  excites 
great  alarm.  The  patient  is  busy  perhaps  at  his  occupation,  or 
enjoying  himself  in  the  midst  of  his  family,  when  suddenly  he  finds 
his  sight  fail,  and  as  evening  advances,  becomes  almost  completely 
blind.  The  medical  attendant  is  immediately  sent  for,  and  is  often 
as  much  amazed,  and  little  less  alarmed  than  the  patient.  He  pro- 
bably finds  the  pupils  dilated,  but  no  other  sign  indicative  of  any 
serious  affection  of  the  head.  He  perhaps  takes  away  blood,  orders 
some  purgative  medicine,  and  pronounces  a  very  unfavorable  prog- 
nosis. To  the  joy  of  all  concerned,  the  patient  wakes  in  the  morn- 
ing with  his  sight  perfectly  restored. 

But  again  on  the  approach  of  evening,  symptoms  are  perceived 
of  returning  blindness.  Objects  appear  as  if  covered  by  a  bluish 
or  greyish  mist,  and  in  the  course  of  a  few  minutes,  the  patient  is 
obliged  to  grope  his  way  hke  a  blind  man.  Candles  are  brought. 
If  he  perceives  that  they  are  present,  they  appear  as  if  glimmering 
through  a  fog,  and  scarcely  ever  enable  him  to  see  with  distinctness. 
The  effect,  however,  of  artificial  light  is  not  uniformly  the  same 
in  this  disease. 

Night  after  night,  the  blindness  returns,  and  becomes  more  and 
more  complete.  For  a  time,  the  restoration  to  vision  through  the 
day  appears  to  be  tolerably  perfect,  but  at  length  the  sight  is  evi- 
dently weak  by  day  as  well  as  by  night.  The  patient  is  affected 
with  photophobia,  and  becomes  near-sighted ;  his  vision  is  more 
and  more  impaired  ;  and,  if  neglected  or  mistreated,  the  disease  ends 
in  incurable  amaurosis. 

It  sometimes  happens,  in  incipient  cases  of  night-bhndness,  that 
the  patient,  though  unable  to  distinguish  even  large  objects  after 

*  Medical  Observations  and  Inquiries,  Vol.   i.  p.  111.  London.  1763. 


629 

sunset  or  by  moonlight,  is  restored  to  a  tolerable  degree  of  sight  by 
the  use  of  candle-light ;  but  in  cases  fully  developed,  even  strong 
artificial  illumination  is  unable  to  affect  in  any  degree  the  sunken 
sensibihty  of  the  retina. 

The  appearances  of  the  eyes  are  different  in  different  cases.  In 
many,  there  is  scarcely  any  change  from  the  appearances  of  per- 
fect health.  Generally,  however,  the  pupils  are  dilated  during  the 
attack,  and  do  not  contract  on  exposing  the  eyes  to  the  light  of  a 
candle  or  of  the  moon.  In  some,  the  pupils  continue  dilated  even 
during  the  day  ;  in  others,  they  are  contracted,  and  evince  a  pain- 
ful irritabihty  on  exposure  to  strong  light.  If  the  patient  happens 
to  look  at  the  direct  rays  of  the  sun,  especially  of  a  tropical  sun, 
or  a  strong  glaring  reflection  of  them,  as  from  the  sea,  pain  and 
temporary  blindness  are  induced,  from  which  he  recovers  by  clos- 
ing his  eyes  for  a  time,  and  retiring  into  the  shade. 

This  disease  does  not  appear  to  be  necessarily  accompanied  by 
any  constitutional  symptoms.  That  such  symptoms  are  occasion- 
ally present,  is  evident  from  the  case  already  quoted,  aad  that  a 
variety  of  them  may  attend,  in  different  instances,  will  appear  ex- 
tremely probable  from  a  consideration  of  the  remote  causes  of  the 
disease. 

Prognosis.  The  duration  of  this  disease,  when  left  to  itself, 
has  been  found  to  vary  from  one  night  to  nine  months.  Its  gene- 
ral period  of  continuance  appears  to  be  from  two  to  three  months, 

Mr.  Bampfield  states  *  that  of  more  than  a  hundred  cases  of 
idiopathic,  and  two  hundred  of  symptomatic  night-bhndness,  which 
had  occurred  in  his  practice,  in  different  parts  of  the  globe,  but 
,  chiefly  in  the  East  Indies,  all  perfectly  recovered.  Hence  he  in- 
fers that,  under  proper  treatment,  the  prognosis  may  be  always  fa- 
vourable.   . 

Europeans  who  have  once  been  affected  with  night-blindness, 
in  the  East  or  West  Indies,  are  particularly  liable  to  a  recurrence 
of  the  disease,  so  long  as  they  remain  in  a  tropical  climate.  Those 
who  have  suffered  from  this  disease  at  some  previous  period,  are 
also  apt  to  be  occasionally  attacked  with  dimness  of  sight  for  some 
minutes,  or  for  short  periods  of  some  nights,  or  to  merely  momenta- 
ry night-blindness. 

Proximate  Cause.  This  periodic  amaurosis  probably  depends 
on  some  pecuhar  state  of  the  choroid,  rendering  the  eye  insensible 
except  to  light  of  a  certain  degree  of  intensity  ;  but  of  the  nature 
of  that  peculiar  state  it  is  impossible  for  us  to  form  any  rational 
supposition.  In  some  cases,  there  is  reason  to  suspect  that  the 
proximate  cause  does  not  affect  the  eye,  but  the  brain. 

Remote  Causes.     1.  Scarpa  is  of  opinion  that  this  disease  is 
most  frequently  sympathetic  of  disorder  of  the  stomach.     When 
this  is  the  case,  the  tongue  is  foul,  the  breath  foetid,  and  the  appe- 
,  tite  deficient. 

*  Medico-Chirurgical  Transactions,  Vol.  v.  p.  47.    London,  1814. 


630 

2.  Suppressed  perspiration,  owing  to  the  coldness  of  the  night- 
air,  has  been  mentioned  as  a  probable  cause. 

3.  Exposure  to  an  unusual  glare  of  light  has  been  known  to  in- 
duce night  blindness,  even  in  this  country:  and  in  w^arra  climates, 
this  cause  frequently  operates  in  the  production  of  this  disease. 
Insolation,  and  in  particular  sleeping  with  the  face  or  head  exposed 
to  the  rays  of  the  sun.  or  to  a  very  strong  hght,  have  been  particu- 
larly mentioned  as  causes. 

4.  A  residence  on  lx)ard  ship  seems  of  itself  to  conduce  to  this 
disease. 

5.  Some  authors  have  considered  night-blindness  as  a  symptom, 
or  as  a  precursor  of  scurvy.  Subsistence  upon  sea-diet  perhaps  fa- 
vours the  one,  as  it  certainly  induces  the  other. 

6.  It  is  a  popular  notion  in  the  East  Indies,  that  the  eating  of 
hot  rice  brings  on  this  disease. 

Subjects.  Of  twelve  cases,  taken  by  Mr.  Bampfield,  as  they 
stood  on  the  list,  it  was  noted  that  seven  had  grey  eyes,  one  dark- 
gre}",  one  black,  three  hazel,  and  one  hazel-brown  :  their  hair 
showed  different  shades  of  colour,  from  light-carroty  to  black  ;  their 
ages  varied  from  twenty  to  thirty-eight. 

Treatment.  1.  If  there  are  signs  of  deranged  digestion,  an 
emetic  is  certainly  indicated  ;  after  which  the  bowels  are  to  be 
cleared  out  by  laxative  clysters,  and  the  use  of  purgatives. 

2.  A  succession  of  blisters  to  the  temples,  of  the  size  of  a  crown 
or  half-crown  piece,  applied  tolerabl}"  close  to  the  external  canthus 
of  the  eye,  has  been  strongly  recommended  by  Mr.  Bampfield. 
He  states  that  under  their  application,  the  retina  appears  to  regain 
its  sensibibilit}',  in  the  same  gradual  manner  as  it  had  been  de- 
prived of  it ;  that  the  first  blister  commonly  enables  the  patient  to 
see  dimly  by  candle-light,  or  to  perceive  objects  without  being  able 
to  discriminate  what  they  are ;  that  in  some  shght  cases,  the  first 
bhster  effects  a  cure :  that  the  second  blister  commonly  enables 
the  patient  to  see  distinctly  by  candle-light,  perhaps  hy  bright 
moon-light,  or  even  half  an  hour  after  sunset,  or  that  the  disease 
intermits  for  short  periods  during  the  night ;  and  that  a  perfect 
recovery  is  often  effected  by  the  second  blister.  When  this  does 
not  happen,  a  third,  fourth,  or  fifth  is  to  be  applied  ;  and  if  the 
disease  still  continues  in  any  considerable  degree,  a  perpetual  blis- 
ter is  to  be  formed  on  each  temple,  and  maintained  till  a  cure  is 
accomplished,  which  generally  takes  place  within  a  fortnight. 

3.  If  ihe  night-blindness  is  attended  with  symptoms  of  scuivy, 
the  use  of  blisters  should  be  deferred,  until  the  scorbutic  disposition 
is  corrected,  by  proper  diet  and  medicines  ;  not  only  because  well- 
founded  apprehensions  ought  to  be  entertained  of  a  scorbutic  ulcer 
forming  on  the  blistered  parts,  but  because  the  night-blindness  is 
often  gradually  got  the  better  of,  as  the  cure  of  the  scurvy  pro- 
ceeds. Mr.  Bampfield  reckons,  that  about  a  third  of  the  cases  of 
scorbutic  night-blindness  resist  the  antiscorbutic  regimen  and  reme- 
dies, and  require  to  be  treated  ultimately  as  idiopathic  cases. 


631 

4.  A  shade  should  be  worn  over  the  eyes,  both  during  the 
treatment  and  for  some  time  after  the  cure,  to  defend  them  from  the 
painful  irritation  occasioned  by  exposure  to  vivid  lights. 

5.  The  eyes  ought  to  be  bathed  three  or  four  times  a-day  with 
cold  water. 

6.  Should  the  above  plan  of  treatment  not  prove  successful,  and 
if  there  is  no  suspicion  of  the  disease  being  attended  with  any 
tendency  to  sanguineous  congestion  in  the  head,  cinchona  may  be 
tried. 

7.  Electricity,  as  a  topical  stimulus  to  the  eye,  has  sometimes 
been  employed  with  success.  Also,  exposing  the  eyes  to  the  va- 
pour of  ammonia,  every  three  or  four  hours.  ' 

8.  In  apoplectic  cases,  general  and  local  depletion  will  of  course 
take  precedence  of  all  other  remedies. 

9.  A  residence  on  shore,  and  a  return  to  Europe,  are  to  be 
recommended  in  obstinate  cases  on  board  ship,  or  in  the  warm 
latitudes.  These  are  also  often  the  only  means  of  preventing  re- 
lapses, in  those  who  have  already  repeatedly  suffered  from  night- 
blindness. 


SECTION  X. DAY-BLINDNESS. 

Although  day-hlindness  is  enumerated  by  all  systematic  au- 
thors on  the  diseases  of  the  eye,  very  little  has  been  recorded  on 
the  subject  from  actual  observation.  A  merely  strumous  intole- 
rance of  light,  the  photophobia  of  the  albino,  or  that  of  a  person 
long  shut  up  in  the  dark,  and  suddenly  brought  out  into  the  glare 
of  day,  must  not  be  confounded  with  a  periodical  amaurosis,  the 
counterpart  of  that  which  we  have  last  considered.  Day-bhndness  is 
mentioned  as  a  symptom  both  of  mydriasis  and  myosis.  In  the 
former  disease,  the  pupil  admits  too  much  light  to  enable  the  pa- 
tient to  see  till  after  sunset.  In  the  latter,  the  contraction  of  the 
pupil  is  supposed  to  relax  in  the  obscurity  of  the  night,  and  the  vi- 
sion in  this  way  to  improve.  On  the  same  principle,  the  patient 
affected  with  incipient  cataract  sees  little  during  the  brightness  of 
the  day,  but  finds  his  sight  in  part  restored  by  the  dilatation  of  the 
pupil,  which  takes  place  in  the  evening. 

Among  the  few  original  observations  tending  to  establish  the  fact 
of  there  being  such  a  disease  as  a  periodic  amaurosis,  which 
makes  its  attack  through  the  day,  and  departs  at  night,  may  be 
quoted  the  following  from  Ramazzini. 

'•I  have  repeatedly  observed,"  says  he,  "among  our  country  peo- 
ple, and  especially  in  boys,  a  thing  sufficiently  strange.  In  March, 
about  the  equinox,  boys  about  ten  years  of  age  were  affected  with 
a  great  degree  of  weakness  of  sight,  so  that  through  the  whole  day 

*  Hevieralopia  of  some  ;  nyctalopia  of  others.  See  note  at  beginning  of  last  sec- 
tion. 


632 

diey  saw  little  or  nothing,  and  wandered  about  the  fields  like  blind 
people  ;  but  when  night  came,  they  saw  again  distinctly.  This 
affection  ceased  without  any  remedy,  and  by  the  middle  of  April, 
the  patients  were  completely  restored  to  sight.  1  frequently 
observed  the  eyes  of  these  boys,  and  found  the  pupils  much  en- 
larged." * 

This  looks  like  an  endemic  or  epidemic  day-blindness ;  but  is 
evidently  too  vague  to  furnish  grounds  for  any  general  conclusions. 
Baron  Larrey  has  recorded  a  remarkable  case  of  sporadic  day-blind- 
ness, occuring  in  an  old  man.  one  of  the  galley-slaves  at  Brest, 
who  had  for  thiity-three  years  been  shut  up  in  a  subterraneous 
dungeon.  His  long  residence  in  darkness  had  had  such  an  effect 
on  the  organs  of  vision,  that  he  could  see  only  under  the  shade  of 
night,  and  was  completely  blind  during  the  day.t 


SECTION    XI. HEMIOPIA.; 

This  term  has  been  used  to  signify  a  partial  blindness,  obscur- 
ing about  a  half  of  the  field  of  vision.  Very  frequently  it  is  the 
right  half,  or  the  left  half  of  all  objects,  which  appears  dark,  and 
that  whether  they  are  regarded  with  one  eye  only,  or  with  both. 
In  other  cases,  only  one  eye  is  affected.  It  is  necessary  also  to  ob- 
serve, that  the  upper  or  the  lower  half  of  the  field  of  vision  may 
appear  dark,  or  that  the  patient,  looking  directly  forwards,  may 
see  tolerably  well  within  a  certain  angle,  but  nothing  to  either  side. 
These  latter  varieties  of  hemiopia  are  less  common  than  that  in 
which  the  right  or  the  left  half  of  each  retina  appears  to  be  insen- 
sible to  light,  but  are  not  less  worthy  of  attention. 

Dr.  WoUaston,  a  few  years  before  his  death,  was  the  means  of 
directing  considerable  attention  to  this  disease,  by  his  paper  On 
Serni-decussation  of  the  Optic  Nerves,  published  in  the  Philo- 
sophical Transactions.  He  had  been  repeatedly  attacked  by  hemi- 
opia, had  repeatedly  met  with  the  disease  in  others,  and  was  led 
from  the  symptoms  to  adopt  a  peculiar  notion  regarding  the  course 
and  distribution  of  the  optic  nerves. 

"  It  is  now  more  than  twenty  years,"  says  he,  "  since  I  vras  first 
attacked  with  the  peculiar  state  of  vision,  to  which  I  allude,  in  con- 
sequence of  violent  exercise  I  had  taken  for  two  or  three  hours  be- 
fore. I  suddenly  found  that  I  could  see  but  half  the  face  of  a 
man  whom  I  met ;  and  it  w^as  the  same  with  respect  to  every 
object  I  looked  at.  In  attempting  to  read  the  name  John.son, 
over  a  door,  I  saw  oxAy  son  :  the  commencement  of  the  name 
being  wholly  obliterated  to  my  view.  In  this  instance  the  loss  of 
sight  was  toward  my  left,  and  was  the  same  whether  I  looked  with 
the  right  eye  or  the  left.     This  bUndness  was  not  so  complete  as 

+  De  Morbis  Artificum,  cap.  xxxviii.     Opera,  p.  363.     Londini,  1718. 
t  Memoires  de  Chivurgie  Militairc,  Tome  i.  p.  G.     Paris,  1812. 

t  Half -vision ,  from  rifxio-u;  half,  and  o-liq  vision.      Vu9us  diviidiaiiis. 


633 

to  amount  to  absolute  blackness,  but  was  a  shaded  darkness  with- 
out definite  outline.  The  complaint  was  of  short  duration,  and  in 
about  a  quarter  of  an  hour  might  be  said  to  be  wholly  gone,  hav- 
ing receded  with  a  gradual  motion  from  the  centre  of  vision  ob- 
liquely upwards  towards  the  left. 

"  Since  this  defect  arose  from  over-fatigue,  a  cause  common  to  ^ 
many  other  nervous  affections,  I  saw  no  reason  to  apprehend  any 
return  of  it,  and  it  passed  away  without  any  need  of  remedy,  with- 
out any  farther  explanation,  and  without  my  drawing  any  useful 
inference  from  it. 

"  It  is  now  about  fifteen  months  since  a  similar  affection  occurred 
again  to  myself,  without  my  being  able  to  assign  any  cause  what- 
ever, or  to  connect  it  with  any  previous  or  subsequent  indisposition. 
The  blindness  was  first  observed,  as  before,  in  looking  at  the  face 
of  a  person  I  met,  whose  left  eye  was  to  my  sight  obliterated.  My 
blindness  was  in  this  instance  the  reverse  of  the  former,  being  to 
my  right  (instead  of  the  left)  of  the  spot  to  which  my  eyes  were 
directed  ;  so  that  I  have  no  reason  to  suppose  it  in  any  manner 
connected  with  the  former  affection. 

"  The  new  punctum  caecum  was  situated  alike  in  both  eyes,  and 
at  an  angle  of  about  three  degrees  from  the  centre  ;  for  when  any 
object  was  viewed  at  the  distance  of  about  five  yards,  the  point  not 
seen  was  about  ten  inches  distant  from  the  point  actually  looked  at. 

"  On  this  occasion  the  affection,  after  having  lasted  with  little 
alteration  for  about  twenty  minutes,  was  removed  suddenly  and 
entirely  by  the  excitement  of  agreeable  news  respecting  the  safe 
arrival  of  a  friend  from  a  very  hazardous  enterprise."  * 

In  consequence  of  reflecting  on  these  attacks  of  hemiopia,  Dr. 
WoUaston  was  led  to  the  following  hypothesis  regarding  the  ar- 
rangement of  the  optic  nerves. 

"  Since  the  corresponding  points  of  the  two  eyes,"  says  he, 
"  sympathise  in  disease,  their  sympathy  is  evidently  from  structure, 
not  from  mere  habit  of  feehng  together,  as  might  be  inferred,  if 
reference  were  had  to  the  reception  of  ordinary  impressions  alone. 
Any  two  corresponding  points  must  be  supplied  with  a  pair  of  fila- 
ments from  the  same  nerve,  and  the  seat  of  a  disease  in  which  sim- 
ilar parts  of  both  eyes  are  affected,  must  be  considered  as  situated 
at  a  distance  from  the  eyes  at  some  place  in  the  course  of  the  nerves 
where  these  filaments  are  still  united,  and  probably  in  one  or  the 
other  thalamus  nervorum  opticorum. 

"  It  is  plain  that  the  cord,  which  comes  finally  to  either  eye  un- 
der the  name  of  optic  nerve,  must  be  regaided  as  consisting  of  two 
portions,  one  half  from  the  right  thalamus,  and  the  other  from  the 
left  thalamus  nervorum  opticorura.t 

*  Philosophical  Transactions  for  1824.     Part  i.  p.  224. 

1-  The  origin  of  the  optic  nerve  is  now  generally  acknowledged  to  be,  not  in  the 
parts  called  thalami  nervorum  opticorum,  as  Dr.  WoUaston  appears  to  have  believed,, 
but  in  the  anterior  pair  of  the  corpora  quadrigemina,  parts  analogous  to  the  optic 
tobes  of  birds  and  reptiles. 

SO 


634 

"According  to  this  supposition,  decussation  ^vill  take  place  only 
between  the  adjacent  halves  of  the  two  nerves.  That  portion  of 
nerve  which  proceeds  from  the  right  thalamus  to  the  right  side  of 
the  right  eye,  passes  to  its  destination  without  interference ;  and  in 
a  similar  manner  the  left  thalamus  will  supply  the  left  side  of  the 
left  eye  with  one  part  of  its  fibres,  while  i  he  remaining  halves  of 
both  nerves  in  passing  over  to  the  eyes  of  the  opposite  sides  must 
intersect  each  other,  either  with  or  without  intermixture  of  their 
fibres. 

"  Now,  if  we  consider  rightly  the  facts  discovered  by  comparative 
anatomy  in  fishes,  we  shall  find  that  the  crossing  of  the  entire 
nerves  in  them  to  the  opposite  eyes,  is  in  perfect  conformity  to  this 
view  of  the  arrangement  of  the  human  optic  nerves.  The  relative 
position  of  the  eyes  to  each  other  in  the  sturgeon,  is  so  exactly  back 
to  back,  on  opposite  sides  of  the  head,  that  they  can  hardly  see  the 
same  object,  they  can  have  no  points  which  generally  receive  the 
same  impressions  as  in  us ;  there  are  no  corresponding  points  of 
vision  requiring  to  be  supplied  with  fibres  from  the  same  nerve. 
The  eye  which  sees  to  the  left  has  its  retina  solely  upon  its  right 
side ;  and  this  is  supplied  with  an  optic  nerve  arising  wholly  from 
the  right  thalamus  :  while  the  left  thalamus  sends  its  fibres  entirely 
to  the  left  side  of  the  right  eye  for  the  perception  of  objects  situated 
on  the  right.  In  this  animal  an  injury  to  the  left  thalamus  might 
be  expected  to  occasion  entire  blindness  of  the  right  eye  alone,  and 
want  of  perception  of  objects  placed  on  that  side.  In  ourselves,  a 
similar  iniury  to  the  left  thalamus  would  occasion  blindness  (as  be- 
fore) to  all  objects  situated  to  our  right,  owing  to  insensibility  of  the 
left  half  of  the  retina  of  both  eyes." 

Having  thus  explained  his  hypothesis.  Dr.  Wollaston  goes  on  to 
relate  the  following  additional  instance  of  hemiopia. 

"A  disorder/'  says  he,  "that  has  occurred  within  my  own 
knowledge  in  the  case  of  a  friend,  seems  fully  to  confirm  this  rea- 
soning, as  far  as  a  single  instance  can  be  depended  upon.  After 
he  had  suffered  severe  pain  in  his  head  for  some  days,  about  the 
left  teinple.  and  toward  the  back  of  the  left  eye,  his  vision  became 
considerably  impaired,  attended  with  other  symptoms  indicating  a 
shght  compression  on  the  brain. 

"  It  was  noi  till  after  the  lapse  of  three  or  four  weeks  that  I  saw 
him,  and  found  that,  in  addition  to  other  affections  which  need  not 
here  be  enumerated,  he  laboured  under  a  defect  of  sight  similar  to 
those  which  had  happened  to  myself,  but  more  extensive,  and  it 
has  unfortunately  been  far  more  permanent.  In  this  case  the 
bhndness  was  at  that  time,  and  still  is,  entire,  with  reference  to  all 
objects  situated  to  the  right  of  his  centre  of  view.  Fortunately, 
the  field  of  his  vision  is  sufficient  for  writing  perfectly.  He  sees 
what  he  writes,  and  the  pen  with  which  he  writes,  but  not  the 
hand  that  moves  the  pen.  This  affection  is,  as  far  as  can  be  ob- 
served, the  same  in  both  eyes,  and  consists  in  an  insensibihty  of 


635 

the  retina  on  the  left  side  of  each  eye.  It  seems  most  probable, 
that  some  effusion  took  place  at  the  time  of  the  original  pain  on 
that  side  of  the  head,  and  has  left  a  permanent  compression  on  the 
left  thalamus.  This  partial  bhndness  has  now  lasted  so  long  with- 
out sensible  amendment,  as  to  make  it  very  doubtful  when  ray 
friend  may  recover  the  complete  perception  of  objects  of  that  side 
of  him." 

Towajds  the  conclusion  of  his  paper,  Dr.  Wollaston  adds  the 
following  notice  of  another  case  of  this  disease. 

"  One  of  my  friends,"  sa3's  he,  "  has  been  habitually  subject  to 
it  for  sixteen  or  seventeen  years,  whenever  his  stomach  is  in  any 
considerable  degree  deranged.  In  him  the  blindness  has  been  in- 
variably to  his  right  of  the  centre  of  vision,  and,  from  want  of  due 
consideration,  had  been  considered  as  temporary  insensibility  of  the 
right  eye ;  but  he  is  now  satisfied  that  this  is  not  really  the  case, 
but  that  both  eyes  have  been  similarly  affected  with  half-blindness. 
This  symptom  of  his  indigestion  usually  lasts  about  a  quarter  of 
an  hour  or  twenty  minutes,  and  then  subsides,  without  leaving 
any  permanent  imperfection  of  sight." 

Dr.  Wollaston  died  about  four  years  after  the  publication  of  the 
paper,  from  which  these  extracts  have  been  taken.  Whether  he 
had  any  third  attack  of  hemiopia,  I  know  not ;  but  in  the  account 
which  has  been  published  of  the  appearances  observed  on  inspecting 
his  body,  we  find  it  stated,  that  the  optic  thalamus  of  the  right  side 
was  of  an  unusually  large  size,  and  that  on  making  a  section  of 
it,  with  the  exception  of  a  layer  of  medullary  substance  on  its  upper 
part,  httle  or  no  vestige  of  its  natural  substance  was  perceptible. 
It  had  been  converted  into  a  tumour,  as  large  as  a  middle-sized 
hen's  egg,  towards  the  circumference  of  a  greyish  colour,  and  harder 
than  the  brain  itself,  somewhat  of  a  caseous  consistence,  but  in  the 
centre  of  a  brown  colour,  soft,  and  in  a  half-dissolved  state.  This 
diseased  structure  was  not  confined  to  the  thalamus,  but  extended 
to  the  neighbouring  portion  of  the  corpus  striatum.  The  right 
optic  nerve,  where  it  passes  on  the  outside  of  the  thalamus,  was  of 
a  brown  colour,  n)ore  expanded,  and  softer  than  natural.* 

The  reader  will  readily  perceive,  that  between  this  state  of  the 
brain  and  the  previous  symptoms  of  hemiopia,  there  may  or  may 
not  have  been  a  connexion  ;  for  there  were  two  distinct  attacks  of 
the  disease,  at  the  interval  of  twenty  years,  each  attack  subsiding 
entirely  after  fifteen  or  twenty  minutes,  in  the  first  attack  objects 
to  the  left  appearing  dark,  and  in  the  second  those  to  the  right. 
We  know  that  morbid  alterations  in  the  substance  of  the  brain 
sometimes  produce  periodic  diseases ;  and  that  certain  additional 
causes  of  excitement  operating  upon  an  unsound  brain,  will  cause 
one  or  other  of  the  functions  of  that  organ  to  be  for  a  time  impeded, 
till  the  new  cause  ceases  to  operate,  when  the  individual  immediate 
ly  returns  to  his  former  state  of  apparent  health. 

*  London  Medical  Gazette,  Vol.  iii.  p.  293.    London,  1829. 


636 

The  following  remarks  have  occurred  to  me,  in  reflecting  on  Dr. 
WoUaston's  paper. 

1.  The  notion  of  a  semi-decussation  of  the  optic  nerves  had  not 
merely  been  entertained  by  several  distinguished  authors,*  before 
Dr.  WoUaston,  but  had  in  some  measure  been  demonstrated  by 
dissection.t  The  idea,  however,  that  the  two  portions,  of  which 
each  optic  nerve  may  be  regarded  as  consisting,  remain  distinct, 
even  after  they  form  the  retina,  is  new,  and  probably  without  foun- 
dation. Dr.  WoUaston  appears  to  have  overlooked  the  fact,  that  as 
the  optic  nerves  pass  through  the  sclerotica  and  choroid  considerably 
nearer  the  middle  line  of  the  body  than  the  centre  of  the  globe  of 
each  eye,  the  two  optic  axes,  which,  if  any  two  points  deserve  to 
be  considered  as  such,  are  surely  corresponding  points,  will  not  be 
formed  by  filaments  from  the  same  nerve,  but  from  opposite  nerves. 
It  has  always  occurred  to  me  as  more  probable,  that  the  two  portions, 
of  which  each  optic  nerve  consists,  mingle  in  the  fibres,  and  then  ex- 
pand into  the  retina,  so  that  the  membrane  in  each  eye  should  be 
regarded  as  a  plexus,  every  point  of  which  contains  fibres  derived 
from  each  side  of  the  brain. 

2.  It  is  not,  however,  by  mere  reasoning  upon  a  subject  Uke  this, 
that  we  can  arrive  at  any  sound  conclusion.  By  far  the  greater  part 
of  the  mass  of  facts,  in  pathological  and  in  what  may  be  called  ex- 
perimental anatomy,  touching  this  question,  go  to  prove,  that  inju- 
ries and  diseases  affecting  one  side  of  the  brain,  instead  of  hemiopia 
in  both  eyes,  produce  amaurosis  only  in  the  opposite  eye.l  The 
fact,  also,  which  has  been  already  mentioned  in  the  beginning  of 
this  section,  that  we  meet  with  a  horizontal  as  well  as  a  perpen- 
dicular hemiopia,  appears  scarcely  reconcileable  to  the  hypothesis 
of  Dr.  WoUaston.  Not  so,  however,  that  other  variety  of  the  dis- 
ease, in  which  objects  to  each  hand  appear  dark,  and  those  only 
which  are  placed  in  front  are  seen  distinctly  :  for  were  any  tumour 
or  excrescence  to  press  on  the  optic  nerves  immediately  anteriorly 
to  their  union,  the  effect  would  be,  according  to  the  hypothesis 
of  i^emi-decussation,  to  paralyse  the  inner  half  only  of  each  letina. 

Treatment.  Hemiopia  being  merely  a  peculiar  variety  of 
amaurosis,  must  be  treated  on  similar  principles.  The  patient's 
constitution,  whether  plethoric  or  debilitated,  the  state  of  his  diges- 
tive organs,  the  presence  or  absence  of  cerebral  symptoms,  as  head- 
ach,  vertigo,  &.c.  must  be  taken  into  account,  and  guide  us  in  the 
choice  of  remedies. § 

*  Vater,  Ackermann,  Vicq-d'Azyr,  Caldani,  Cuvier,  &c. 

t  Josephus  et  Carolus  "Wenzel  de  Penitiori  Structura  Gerebri,  pp.  109,  233.  Tu- 
bingae,  1812, 

t  Serres,  Anatomic  Comparee  du  Cerveau,  Tome  i.  p.  331.     Paris,  1827. 

§  On  the  subject  of  hemiopia,  the  reader  may  consult — Arago,  Annates  de  Chimie, 
Tome  xxvii.  p.  109.— Crawford,  Medical  and  Physical  Journal,  Vol.  liii.  p.  48. — 
Pravaz,  Archives  Generales  de  Medecine,  Tome  viii.  p.  59 ;  Tome  ix.  p.  485. 


637 


SECTION  XII. AMBLYOPIA,*  OR  WEAKNESS  OF  SIGHT. 

To  some  it  may  appear  improper,  to  say  any  thing  under  tliis 
head,  as  it  is  well  known  that  there  is  no  specific  disease  to  which 
the  name  amblyopia  ought  to  be  appropriated,  and  that  v)eakness 
of  sight  is  a  complaint  symptomatic  of  many  and  very  different 
kinds  of  disease.  The  oculist  will  find,  that  many  of  those  cases 
which  come  before  him  under  the  name  of  weakness  of  sight,  have 
existed  for  a  long  period,  and  withstood  a  variety  of  remedies,  be- 
cause they  have  never  been  carefully  investigated,  nor  accurately 
discriminated.  Lingering  ophthalmia,  perhaps  catarrhal,  perhaps 
strumous,  chronic  iritis  or  retinitis,  photophobia,  nebulous  cornea, 
incipient  cataract,  ophtlialmia  tarsi,  epiphora  from  disordered  sto- 
mach, slight  blenorrhoea  of  the  lachrymal  passages,  an  inverted 
eyelash,  myopia,  presbyopia,  photopsia,  muscse  voUtantes,  incipient 
amaurosis,  and  many  other  affections  of  the  organ  of  vision,  from 
carelessness,  or  ignorance,  are  often  set  down  as  weaktiess  of  sight. 
Nay,  treatises  have  been  written  on  weakness  of  sight,  and  the 
proximate  cause  of  what  is  merely  a  symptom  of  many  and  various 
diseases  has  been  gravely  investigated  ;  modes  of  treatment  have 
been  proposed  for  weakness  of  sight,  and  empirical  cures,  equally 
surprising  to  the  patient  and  the  practitioner,  have  sometimes  been 
accomphshed. 


CHAPTER  XIX. 

AMAUROSIS.t 

SECTION  I. GENERAL    ACCOUNT  OF  AMAUROSIS. 

I.  Definitio7i.  By  amaurosis  is  meant  an  obscurity  of  vision, 
arising  from  a  more  or  less  insensible  state  of  one  or  more  of  the 
nervous  parts,  which  assist  in  forming  the  optic  apparatus.  If  the 
retina  be  incapable  of  receiving  with  correctness,  impressions  of 
external  objects  through  the  medium  of  light,  if  the  oplic  nerve  be 
unable  to  convey  to  the  sensorium  the  impressions  made  upon  the 
retina,  or  if  the  sensorium  be  incapable  of  receiving  the  impressions 
conveyed  by  the  optic  nerve,  the  individual  must  necessarily  be 
affected  with  a  greater  or  less  obscurity  in  vision,  or  suffer  a  total 
deprivation  of  vision,  according  to  the  degree  of  inability  in  these 
several  parts  to  execute  their  functions.     Even  when  he  goes  no 

*  From  'etf^^Kv;  dull,  and  a>^  the  eye.  The  term  appears  to  be  employed  by  Hip- 
pocrates, to  signify  impaired  vision,  unattended  by  any  appearance  of  opacity  in  the 
eye. 

T  From  ctfAsugog,  obscure.  Gutta  serena  of  the  Arabians.  Der  schwarze  Staar  of 
the  Germans. 


'      638 

farthei'  thaa  this,  the  pathologist  must  see  the  necessity  of  distia- 
guishing  different  cases  of  amaurosis,  according  as  the  retina,  the 
optic  nerve,  or  the  brain,  is  the  part  first  and  principally  affected. 
II.  Seat.  In  order  to  prevent,  if  possible,  our  falling  into  false 
notions  regarding  the  seat  of  amaurosis,  it  may  be  proper  to  recall 
to  mind  the  following  anatomical  and  physiological  facts. 

1.  The  optic  nerves  originate,  a  little  behind  the  middle  of  the  cer- 
ebral mass,  from  the  anterior  pair  of  the  corpora  quadrigemina ; 
and  are,  therefore,  in  communication  with  the  posterior  part  of  the 
medulla  oblongata.  The  broad  shp  of  medullary  substance  by 
which  the  nerve  seems  on  each  side  to  commence,  turns  round 
upon  the  outer  edge  of  the  mass  commonly  called  the  thalamus, 
crosses  the  crus  cerebri,  attaches  itself  to  the  middle  and  anterior 
lobes  of  the  cerebrum,  forms  an  intimate  connexion  with  the  tuber 
cinereum,  and  continues  its  course  till  it  meets  its  fellow-nerve  of 
the  opposite  side. 

2.  Numerous  cases  on  record,  in  wliich  atroph)^  of  one  of  the 
optic  nerves  has  been  traced  from  a  diseased  eye  to  the  opposite 
side  of  the  brain,  fully  establish  the  fact  of  at  least  a  partial  de- 
cussation of  the  optic  nerves.  The  outermost  fibres  of  each  nerve 
appear  to  continue  their  course  toward  the  orbits  without  decussa- 
ting ;  probably  the  innermost  fibres  pass  from  the  one  side  to  the 
other. 

3.  There  is  no  proportion,  and  but  slight  connexion,  between 
the  optic  thalami  and  the  nerves  of  vision.  In  the  horse,  ox, 
sheep,  &c.  the  optic  nerves  are  as  large  as  in  man,  but  the  thalami 
in  man  are  much  larger  than  in  those  animals.  On  examining 
the  structure  of  tlie  thalamus,  it  is  found  that  a  mere  superficial 
layer  of  it  is  attached  to  the  optic  nerve,  and  that  the  whole  of  its 
interior  fibres  diverge  backwards  into  the  cerebral  convolutions. 
When  the  optic  nerve  is  affected  with  atrophy,  the  corresponding 
thalamus  is  diminished  only  in  as  far  as  the  nerve  itself  has 
shrunk  ;  the  interior  of  the  thalamus  suffers  no  change,  but  the 
atrophic  state  of  the  nerve  may  be  traced  back  to  the  corpora  quad- 
rigemina. Dr.  Spurzheim  tells  us,  that  he  once  found  in  the 
brain  of  a  woman  who  had  died  insane,  the  thalamus  of  the  left 
side  half  converted  into  pus,  the  corpus  striatum  of  the  same  side 
much  shrunk,  but  the  optic  nerve  healthy,  and  resembling  in  all 
respects  its  fellow  of  the  opposite  side,  in  the  vicinity  of  which  no 
organic  change  could  be  detected.  The  anterior  pair  of  quadrige- 
minal  bodies  were  also  in  their  natural  state.* 

4.  Each  retina  is  probably  a  plexus,  derived  nearly  equally 
from  the  two  optic  nerves.  But  besides  these,  there  is  reason  to 
beUeve  that  the  retina  is  in  communication  with  other  nerves  ; 
that  it  influences  them,  and,  on  the  other  hand,  is  under  their  in- 
fluence.    If  we  trace  the  great  sympathetic  nerv^e  upwards  from 

*  Anatomy  of  the  Brain,  p.  80.    London,  1826. 


639 

the  first  cervical  ganglion,  we  find  that  its  branches,  the  principal 
of  which  are  two  in  number,  surround  the  internal  carotid  artery, 
and  pass  with  it  into  the  carotid  canal  of  the  temporal  bone. 
Within  the  cavernous  sinus,  the  great  sympathetic  forms  a  gan- 
glion, whence  are  derived  branches  which  communicate  with  the 
nerves  of  the  sixth  pair,  third  pair,  and  first  division  of  the  fifth 
pair.  One  or  more  branches  of  the  cavernous  ganglion  communi- 
cate directly  with  the  lenticular  ganghon.  The  internal  carotid 
artery,  as  it  mounts  into  the  cranium,  is  still  surrounded  by  branches 
of  the  great  sympathetic  nerve,  which  cling  to  it,  and  may  be  traced 
along  all  its  ramifications.  The  ophthalmic  artery,  with  the  rest,  is 
invested  with  a  plexus  from  this  nerve,  and  in  this  way  the  arte- 
ries of  the  choroid,  iris,  and  retina,  are  supplied  with  its  influence. 
From  the  lenticular  ganglion  arise  the  nerves  of  the  iris,  and  one 
anatomist*  supposes  that  he  has  traced  branches  from  the  ciliary 
or  iridal  nerves,  where  they  lie  between  the  sclerotica  and  choroid, 
which  penetrate  the  latter  membrane,  and  run  backwards  into  the 
retina. 

5.  If,  in  birds,  we  wound  one  of  the  optic  lobes,  parts  analo- 
gous to  the  anterior  corpora  quadrigemina  of  n)ammiferous  ani- 
mals, the  vision  of  the  opposite  eye  becomes  weak  or  extinct ;  and 
if,  after  a  time,  the  same  experiment  is  performed  on  the  other 
side  of  the  brain,  the  eye  which  formerly  continued  sound,  becomes 
bhnd.t 

6.  If  the  optic  nerve  is  divided  in  any  animal,  anteriorly  to  the 
decussation  of  the  two  nerves,  the  pupil  of  the  eye  on  the  same 
side  becomes  very  large  and  motionless,  and  the  power  of  vision 
of  that  eye  is  immediately  abolished.  Every  trace  of  sensibility 
to  light  is  lost,  so  that  even  on  concentrating  the  light  of  the  sun 
by  means  of  a  lens,  and  directing  it  into  the  pupil,  not  the  least 
appearance  of  sensation  is  produced. 

7.  It  is  generally  acknowledged,  that  the  fifth  pair  of  nerves 
communicate  common  sensibility  to  the  parts  to  which  they  are 
distributed  ;  but  over  the  eye,  they  certainly  exercise  a  very  remark- 
able, and  at  present,  inexplicable  influence.  If  the  trunk  of  the 
fifth  pair  of  nerves  is  divided  in  rabbits,  guinea  pigs,  dogs,  or  cats, 
besides  other  effects,  which  show  the  great  influence  of  the  fifth 
pair  over  the  nutrition  of  the  eye,  there  are  immediately  produced 
fixed  contracted  pupil  in  the  first  two  animals,  fixed  expanded  pu- 
pil in  the  last  two,  and  blindness,  almost  as  complete  as  when  the 
optic  nerve  is  divided,  in  all.  In  the  rabbit,  it  is  believed,  that  the 
ciliary  or  iridal  nerves  are  derived  solely  from  the  third  pair,  and 
that  they  do  not  form  any  lenticular  ganglion  ;  in  the  cat,  there 
is  a  lenticular  ganghon,   as  in  man,  formed   partly  by  the  third, 

*  Ribes,  Memoires  de  la  Societe  Medicate  d'EmuIation,  Tome  vii.  p.  99.  Paris 
1811. 

t  Magendie,  Journal  de  Physiologie,  Tome  iii.  p.  376.  Paris,  1823.  Series, 
Anatomie  Comparee  du  Cerveau,  Tome  L  p.  331.    Paris,  1827. 


640 

and  partly  by  the  fifth  pair.  It  scarcely  admits  of  a  doubt,  that  the 
integrity  of  the  fifth  pair  is  a  necessary  condition  for  the  action  of 
the  retina  as  a  sentient  organ.* 

8.  If  the  trunk  of  the  third  pair  be  divided  within  the  cranium 
of  a  pigeon,  the  pupil  dilates,  and  cannot  be  made  to  contract  by 
exposure  to  intense  Mght.  The  section  of  the  fifth  pair  in  the  same 
animal  produces  no  change  in  the  alternate  motions  of  the  iris. 
In  birds,  the  third  pair  supplies  the  whole  of  the  nerves  of  the  iris. 
When  the  optic  nerves  are  pinched  within  the  cranium  of  a  pigeon, 
the  pupils  contract.  The  same  result  follows  a  similar  irritation 
of  the  third  pair,  but  not  that  of  the  fifth.  When  the  optic  nerves 
have  been  divided  within  the  cranium  of  a  pigeon,  if  the  portion 
of  the  nerves  attached  to  the  eyes  be  pinched,  no  contraction  of  the 
pupil  ensues ;  but  if  the  portion  adhering  to  the  brain  be  pinched, 
a  hke  contraction  of  the  pupil  ensues  as  if  the  optic  nerves  had  not 
been  divided.  If  the  third  pair  has  been  divided,  no  change  in  the 
pupil  ensues  on  irritating  the  entire  or  divided  optic  nerves.  From 
these  facts,  it  may  fairly  be  concluded,  that  in  the  habitual  varia- 
tions of  the  pupil,  an  impression  is  conveyed  along  the  optic  nerve 
to  the  brain,  which  is  followed  by  an  affection  of  the  third  pair, 
causing  the  pupil  to  contract  or  dilate.t 

9.  If  the  great  sympathetic  be  divided  on  one  side  of  the  neck 
of  a  dog,  the  pupil  becomes  fixed  and  contracted,  and  the  nutrition 
of  the  eye  is  interrupted.  If  the  experiment  be  performed  on  both 
sides,  the  pupils  become  fixed  and  dilated.  Petit  considers  these 
different  effects  as  analogous  to  w4iat  takes  place  in  amaurosis ; 
for  if  one  eye  only  be  amaurotic,  the  pupil  of  that  eye  does  not,  in 
general,  become  dilated  :  but  if  both  eyes  be  blind,  both  pupils 
dilate.t 

From  these  anatomical  and  physiological  facts,  I  do  not  mean, 
for  the  present,  to  draw  any  farther  conclusions  than  these,  that 
any  strict  inquiry  into  the  seat  of  the  different  varieties  of  amaurosis, 
will  necessarily  embrace  a  field  of  considerable  extent,  and  that  we 
need  not  be  surprised  to  meet,  in  the  course  of  such  inquiry,  with 
many  facts,  which  ma}^  appear  not  only  inexplicable,  but  even  con- 
tradictory. Our  knowledge  of  the  connexions  and  operations  of 
the  nervous  system  is  only  in  its  infancy;  and  we  must  beware, 
therefore,  equally  of  the  tendency  of  those,  who  would  venture, 
upon  the  faith  of  a  few  defective  data,  to  explain  every  thing  in 
nervous  diseases,  and  of  those,  who,  shrinking  themselves  from  the 
task  of  endeavouring  to  unravel  a  series  of  phenomena  of  multiplied 
diversity,  and  no  little  intricacy,  would  affect  to  despise  the  merito- 
rious, though  imperfect  labours  of  our  predecessors. 

*  Magendie,  Journal  de  Physiologic,  Tome  iv.  pp.  176,  302.  Paris,  1824.  Des- 
moulins,  Anatomie  des  Systemes  Nevveux,  Tome  ii.  p.  712.     Paris,  1825. 

t  Mayo's  Anatomical  and  Physiological  Commentaries.  No.  ii.  p.  4.  London, 
1823.  F  > 

t  Memoires  de  I'Academie  Royale  des  Sciences,  1727,  p.  1.     Amsterdam,  1732. 


641 

III.  Causes.  Very  different  efficient  causes  have  been  found 
to  operate  in  the  production  of  amaurosis.  In  some  cases,  the 
cause  has  been  found  to  be  of  a  local,  direct^  and  mechanical 
nature ;  such  as  the  pressure  of  a  tumour  on  the  optic  nerve.  In 
other  cases,  it  has  been  of  a  local,  but  vital  kind ;  such  as  a  ple- 
thoric or  congested  state  of  the  blood-vessels  of  the  brain  or  of  the 
eye.  In  a  third  set  of  cases,  the  cause  has  been  general  or  con- 
stitutional ;  such  as  exhaustion,  consequent  to  profuse  or  continued 
loss  of  some  of  the  fluids  of  the  body. 

The  proximate  cause  of  amaurosis  is  evidently,  in  by  far  the 
greater  number  of  cases,  pressure.  The  pressure  oif  an  exostosis, 
or  other  tumour,  or  of  gorged  blood-vessels,  upon  the  optic  appara- 
tus, is  an  idea  with  which  we  are  familiar,  and  regarding  the 
reality  of  which,  medical  practitioners,  in  general,  feel  no  hesita- 
tion ;  but  even  when  amaurosis  is  the  result  of  inflammation,  it 
can  scarcely  be  doubted,  that  the  brain  suffers  a  certain  kind  of 
pressure,  which  renders  it  incapable  of  fulfilling  its  proper  functions. 
One  author,  however,  of  high  name,  has  promulgated  a  somewhat 
different  view  of  the  proximate  cause  of  those  diseases,  which  are 
generally  attributed  to  compression  of  the  brain.  That  we  have 
no  more  right  to  believe  that  the  substance  of  the  brain  admits  of 
being  compressed  than  that  water  is  compressible,  appears  to  be  the 
opinion  of  Mr.  C.  Bell,  who  maintains,  that  what  is  called  com- 
pression of  the  brain,  operates  not  on  the  substance  of  the  brain 
itself,  but  simply  by  preventing  that  due  supply  of  arterial  blood, 
which  is  necessary  for  the  performance  of  the  cerebral  functions. 

I  need  scarcely  mention,  that  amaurosis  always  results  from  an 
organic  cause.  The  notion  of  such  a  thing  as  a  functional  am- 
aurosis appears  to  have  arisen  from  the  facts,  that  this  disease  is 
sometimes  sympathetic,  or  arises  in  consequence  of  derangement 
of  some  remote  organ,  and  that  it  is  occasionally  sudden  in  its  at- 
tack, or,  on  the  other  hand,  instantaneous  in  its  departure.  It 
cannot,  however,  admit  of  doubt  for  a  moment,  that  even  in  cases 
of  sympathetic  amaurosis,  the  loss  of  sight  must  depend  on  some 
organic  change  in  the  optic  apparatus.  Take,  for  example,  the 
amaurosis  which  arises  from  the  presence  of  worms  in  the  bowels. 
This  result  is  only  occasional ;  the  brain,  of  perhaps  not  more  than 
one  out  of  a  hundred  affected  with  worms,  is  so  susceptible  of  dis- 
ease, that  the  irritation  communicated  to  it,  from  the  bowels, 
through  the  great  sympathetic  nerve,  is  sufficient  to  excite  it  to  that 
morbid  condition,  which  causes  dilatation  of  the  pupils  and  loss  of 
vision ;  but  that  the  amaurosis,  in  these  cases,  is  the  consequence 
of  any  thing  else  than  a  certain  morbid  condition  of  the  optic  ap- 
paratus, is  a  proposition  which  scarcely  deserves  a  serious  refutation. 
Neither  can  it  be  admitted,  when  amaurosis  occurs  suddenly,  as 
a  disease  of  relation,  that  it  is  independent  of  organic  derangement 
"  in  the  optic  apparatus,  however  indubitable  it  may  be  that  the  first 
link  in  the  chain  of  causes  has  existed  in  some  remote  part  of  the 
81 


642 

body.  Dr.  Abercrombie*  mentions  the  case  of  a  gentleman  who 
after  an  apoplectic  attack  lost  his  sight,  and  continued  in  a  state  of 
perfect  blindness  for  about  seven  years.  After  that  time,  while  one 
day  out  in  his  carriage,  he  suddenly  recovered  sight.  Such  an 
occurrence  as  this  is  more  favourable  to  the  notion  in  question,  than 
perhaps  any  other  which  could  be  adduced  ;  and  yet  the  only  ra- 
tional conclusion  which  can  be  drawn  from  it  is  evidently  this,  that 
cases  of  amaurosis,  even  of  long  standing,  may  sometimes  depend 
on  cerebral  derangements,  capable  of  being  entirely  and  instantane- 
ously removed. 

Remote  causes.  Amaurosis  springs  from  a  great  variety  of  pre- 
disposing and  exciting  causes. 

1.  We  meet  with  instances  of  a  hereditary  predisposition  to  this 
disease ;  so  that  several  members  of  the  same  family,  or  of  succes- 
sive families,  lose  their  sight,  about  the  same  period  of  life.  Beer 
knew  several  families  who  had  a  hereditary  tendency  to  amaurosis. 
In  one  of  them,  all  the  females,  even  to  the  third  generation,  who 
had  not  born  children,  became  blind,  when  they  ceased  to  menstru- 
ate. The  males  of  this  family,  who  as  well  as  the  females,  had 
dark-brown  eyes,  also  shewed  a  decided  tendency  to  this  disease, 
although  none  of  them  lost  their  sight.t 

2.  Over-exertion  of  the  sight,  exposure  of  it  to  bright  light,  occu- 
pation of  it  upon  minute  objects,  and  employment  of  the  eyes  dur- 
ing the  hours  which  ought  to  be  devoted  to  sleep,  form  a  set  of 
causes  which  are  extremely  productive  of  amaurosis.  In  many  in- 
stances, a  single  imprudent  exposure  of  the  eye  to  the  operation  of 
some  such  cause  as  those  now  mentioned,  has  been  sufficient  to 
extinguish  the  sensibility  of  the  retina ;  but,  in  general,  it  is  from 
long-continued  over-exciteraeut  of  the  organs  of  vision,  that  they 
begin  to  fail,  and  at  last  become  totally  unable  to  continue  their 
office. 

3.  A  third  set  of  predisposing  and  exciting  causes  are  such, 
as  promote  a  tendency  to  sanguineous  congestion,  or  serous  effusion, 
in  the  head  ;  such  as  insolation,  rage,  forced  exertions  of  the  body, 
occupations  which  require  continued  stooping,  errors  in  diet,  and 
especially  the  abuse  of  wine  and  spirits,  retrocession  of  eruptive  dis- 
eases, suppiessed  discharges,  interruption  or  entire  cessation  of  the 
menses,  and  slowness  of  the  bowels. 

4.  The  operation  of  poisonous  substances  sometimes  produces  a 
sudden  attack  of  amaurosis.  Belladonna,  stramonium,  and  some 
other  narcotics,  in  any  considerable  dose,  are  almost  immediately 
followed  by  this  effect.  Other  poisonous  substances,  applied  to  the 
body,  in  small  quantities  every  day,  or  several  times  every  day, 
are  probably  productive  of  a  sin)ilar  effect,  only  (hat  they  operate 
more  slowly.     I  am  inclined  particularly  to  signalize  tobacco  as  a 

*  Pathological  and  Practical  Researches  on  Diseases  of  the  Brain,  p.  309.     Ed- 
inburgh, 1829. 
t  Lehre  von  den  Augenkranheiten,  Vol.  ij.  p.  443.    Wien,  1817. 


643 

poison  of  this  sort ;  but  many  others  have  been  accused  of  an 
insidious  operation  on  the  nervous  system,  terminating  in  blind- 
ness. 

5.  Gastric  and  intestinal  irritation,  acute  or  chronic,  is  in  many 
instances  the  forerunner  of  amaurosis,  and  evidently  operates  as  its 
exciting  cause. 

6.  Exhaustion  of  the  body,  such  as  that  which  arises  from 
chronic  diarrhoea,  excessive  venery,  long-continued  grief,  prolonged 
suckling,  typhus  fever,  and  the  like,  is  a  frequent  cause  of  amauro- 
sis. 

7.  Blows  on  the  head,  injuries  of  the  branches  of  the  fifth  pair 
of  nerves,  and  even  mere  irritation  of  this  nerve,  have  sometimes 
proved  the  remote  causes  of  amaurosis. 

8.  Those  who  have  suffered  from  strumous  ophthalmia  in 
childhood  are  very  liable  to  become  amaurotic,  after  they  begin 
to  use  their  eyes  in  earnest,  and  especially  if  they  are  exposed 
to  one  or  more  of  the  unfavourable  influences  just  now  enumerated. 

Complication  of  causes.  If  we  investigate  with  care  the  his- 
tory of  those  cases  of  amaurosis  which  come  before  us,  we  shall  find 
that  this  disease  can  rarely  be  attributed  to  the  influence  of  any 
single  remote  cause;  but  that  most  frequently  a  number  of  circum- 
stances, favourable  to  the  rise  and  progress  of  an  amaurotic  affec- 
tion, have  for  a  length  of  time  been  acting  on  the  individual.  It  is 
chiefly  this  combination  of  causes,  which  at  once  renders  it  so  dif- 
ficult to  discriminate  with  correctness  between  the  different  species 
of  amaurosis,  to  classify  them,  and,  in  many  cases,  to  decide  on  a 
proper  line  of  treatment,  and  which  but  too  often  serves  also  to  frus- 
trate the  cure,  even  when  tht;  remedies  aie  judiciously  selected,  and 
carefully  applied. 

IV.  Symptoms.  The  symptoms  of  amaurosis  naturally  arrange 
themselves  into  two  classes ;  the  objective  and  the  subjective. 
The  former  class  includes  those  which  the  observer  discovers  in 
the  form,  colour,  texture,  consistency,  vascularity,  and  mobility  of 
the  different  parts  of  the  organ  of  vision,  or  in  the  general  health 
of  the  patient ;  the  latter,  those  which  the  patient  himself  expe- 
riences, and  which  must  be  admitted  very  much  upon  his  own 
testimony,  as  impaired  and  deranged  vision,  headach,  giddiness, 
&,c.  In  general,  it  is  advisable  in  examining  any  case  of  amauro- 
sis, first  to  attend  to  the  objective,  and  then  to  the  subjective  symp- 
toms. Each  eye  ought  also  to  be  inspected  separately,  and  with 
the  other  excluded  from  the  light.  Even  in  the  history  of  his 
loss  of  vision,  we  ought  to  confine  the  patient  to  one  eye  at  a  time, 
unless  both  appear  to  have  become  affected  at  the  same  period, 
and  from  the  same  cause. 

/.  Objective  symptoms.  I.  The  first  symptom,  which,  in  gen- 
eral, attracts  the  attention  of  an  experienced  observer,  is  the  gait, 
and  cast  of  eye,  of  the  amaurotic  patient.  He  advances  towards 
us  with  an  air  of  uncertainty  in  his  movements,  from  which  the 


644 

cataractous  patient  is  in  a  great  measure  or  altogether  exempt, 
and  instead  of  converging  his  eyes  in  the  natural  way  towards  an 
object,  it  is  evident  that  there  is  something  staring  and  unmeaning 
in  his  look.  This  latter  symptom,  which  Richter  *  appears  to 
confound  with  squinting,  may  exist,  indeed,  only  in  a  very  shght 
degree.  It  is,  however,  as  that  author  well  observes,  the  only  ob- 
jective sign  of  amaurosis,  which  never  fails  to  be  present,  a  fact 
peculiarly  valuable,  in  cases  where  we  have  reason  to  suspect  sim- 
ulation on  the  part  of  the  patient.  In  some  cases  of  amaurosis, 
there  is  not  merely  the  want  of  control,  of  which  we  are  now 
speaking,  and  which  is  the  evident  consequence  of  want  of  sensa- 
tion, but  there  is  actual  strabismus,  in  many  oscillation,  and  in 
some  the  eyes  stand  completely  fixed  in  the  head. 

The  motions  of  the  lids,  also,  as  well  as  those  of  the  eyes,  are 
not  unfrequently  impeded  ;  in  some,  the  levator  of  the  upper  lid 
being  partially  or  completely  palsied,  and  in  others,  the  orbicularis 
palpebrarum,  according  as  the  motor  ocuh,  or  the  facial  nerve  is 
prevented  from  communicating  their  natural  degree  of  influence  to 
the  muscles  which  they  supply. 

2.  Besides  the  movements  of  the  eyes,  their  prominence,  colour, 
consistence,  and  form,  deserve  attention.  We  often  observe  them 
unnaturally  prominent,  or  the  one  more  prominent  than  the  other  ; 
their  colour  is  seldom  that  of  the  healthy  eye,  the  sclerotica  being 
fi-euqently  of  a  yellowish  hue,  sometimes  blueish  or  ash-coloured, 
and  often  covered  with  varicose  vessels;  while  there  are  few 
symptoms  of  amaurosis  so  certain  as  a  change  in  the  consistence  of 
the  eyeball,  it  being  either  considerably  firmer  to  the  touch,  or  greatly 
softer  than  natural.  In  some  instances,  we  find  the  eye  flattened 
on  one  or  several  of  its  sides. 

3.  Sluggish  and  limited  motion  of  the  pupil,  or  entire  loss  of 
motion,  often  attended  with  dilatation,  sometimes  with  contraction 
of  that  aperture,  forms  one  of  the  most  remarkable  symptoms  of 
amaurosis.  Widely  dilated  fixed  pupil  is  generally  regarded  as  a 
sign  of  pressure  on  the  brain.  For  example,  it  almost  always  at- 
tends hydrocephalus,  and  fractured  cranium  with  depression  ;  but 
that  this  state  of  the  pupil  is  not  always  connected  with  pressure 
on  the  brain,  nor  even  with  any  cerebral  disease,  is  evident  from 
the  fact,  that  it  is  sometimes  induced  simply  by  a  blow  on  the  eye. 
The  early  and  incomplete  stages  of  amaurosis  are  rarely  accom- 
panied by  widely  dilated  pupil ;  but  after  the  perception  of  light  is 
altogether  extinct,  this  opening  is  generally  found  expanded,  and 
quite  motionless. 

There  are  two  facts  regarding  the  motions  of  the  pupil  in  cer- 
tain amaurotic  cases,  which  have  attracted  much  attention.  The 
first  is,  that  the  pupil  of  a  completely  amaurotic  eye  will  often 
move  briskly,  according  to  the  degee  of  light  acting  on  the  opposite 

•  AnfangsgrUnde  der  Wundarzneykunst.    Vol.  iii.  p.  423.     Gottingen,  1804. 


645 

or  sound  eye,  while,  if  we  expose  the  amaurotic  eye  by  itself,  its 
pupil  remains  perfectly  motionless,  and  much  dilated.  The  second 
fact,  and  one  accounted  still  more  extraordinary,  is  that  in  some 
cases,  where  the  patient  is  totally  blind,  both  pupils,  according  to 
the  intensity  of  light  to  which  the  eyes  are  exposed,  vary  in  diam- 
eter exactly  as  in  health.* 

The  latter  of  these  facts  has  hitherto  received  no  probable  ex- 
planation ;  for  the  idea  t  of  the  iris  acting  in  such  cases,  by  a  sym- 
pathy with  the  retina,  independent  of  the  brain,  is  altogether  con- 
trary to  the  physiology  of  the  iris,  as  founded  on  experiment.  It 
appears  to  be  absolutely  necessary  for  the  motions  of  that  mem- 
brane, not  only  that  the  retina  and  the  iridal  nerves  shall  be  sound, 
but  that  a  certain  degree  of  communication  of  both  shall  be  kept 
up  with  the  brain. 

It  becomes,  then,  a  question,  whether  the  brain  may  not  be  so 
affected  with  disease,  as  to  be  incapable  of  acting  as  the  organ  of 
visual  perception,  and  yet  retain  the  power  of  communicating  to 
the  third  pair  the  impulse  necessary  for  the  usual  motions  of  the 
pupil.  Now,  if  we  suppose  that  the  function  of  vision  is  accom- 
plished only  where  the  optic  nerves  reach  the  corpora  quadrigemina, 
and  thus  communicate  with  the  posterior  part  of  the  medulla  ob- 
longata, but  that  the  association  which  undoubtedly  exists  between 
the  optic  nerves  and  the  third  pair,  is  accomplished  farther  forward 
on  the  basis  of  the  brain,  we  shall  be  able  to  afford,  at  least,  a  plausi- 
ble explanation  of  the  fact  in  question.  The  third  pair  makes  its 
appearance  immediately  behind  the  tuber  cinereum,  a  part  of  the 
brain  with  which  the  optic  nerves  have  a  manifest  connexion. 
The  third  pair  does  not,  indeed,  appear  to  take  its  origin  from  the 
tuber  cinereum,  but  from  the  central  cineritious  substance  of  the 
crura  cerebri,  bearing  an  analogy,  along  with  the  fourth,  sixth, 
seventh,  and  ninth  pairs,  and  the  portion  of  the  fifth  pair  which 
escapes  the  Gasserian  ganglion,  to  the  anterior  roots  of  the  spinal 
nerves ;  but  it  is  surely  not  an  improbable  supposition,  that  the 
optic  nerve,  either  where  it  crosses  the  crus  cerebri,  or,  more  proba- 
bly, where  it  communicates  with  the  tuber  cinereum,  forms  that 
link  of  connexion  with  the  third  pair,  which  it  is  universally  ac- 
knowledged to  do  in  some  part  or  other  of  its  course.  A  disease, 
then,  affecting  the  corpora  quadrigemina,  or,  in  other  words,  the 
origin  of  the  optic  nerves,  on  affecting  any  part  between  the  corpora 
quadrigemina,  and  the  communication  between  the  optic  nerves 
and  the  third  pair,  wherever  that  communication  is  affected,  will, 
according  to  this  view  of  the  subject,  produce  blindness,  but  may 
leave  unimpaired  the  influence  of  the  optic  nerves  upon  the  third 
pair ;  while,  on  the  other  hand,  the  cases  of  fixed  and  dilated  pu- 
pils, in  amaurosis,  are  probably  owing,  either  to  more  extensive 
disease,  or  to  disease  so  situated  as  to  affect  that  part  of  the  brain 

*  Janin,  Memoires  et  Observations  sur  I'CEil,  p.  426.     Lyon,  1772. 

t  Travers's  Synopsis  of  the  Diseases  of  the  Eye,  p.  188.    London,  1820. 


646 

where  the  optic  nerves  communicate  their  influence  to  the  third 
pair.  This  conjecture  receives  no  inconsiderable  support  from  a 
case,  shortly  recorded  by  Mr.  Travers,  of  circumscribed  tumour 
compressing  the  left  optic  nerve,  immediately  behind  the  ganglion 
opticum,  by  which  1  suppose  he  means  the  thalamus.  In  that 
case  the  blindness  was  complete,  but  the  iris  was  active.* 

If  the  above  be  the  true  explanation  of  that  activity  of  the  pupils, 
which  sometimes  exists  in  cases  of  total  blindness,  it  will  also  serve 
to  account  for  the  motions  of  the  iris  of  an  amaurotic  eye,  when 
exposed  along  with  the  opposite  sound  eye,  to  various  gradations 
of  light.  The  right  eye,  we  shall  say,  is  healthy,  but  the  left,  on 
account  of  some  morbid  change  in  the  retina,  or  in  that  portion  of 
its  nerve  which  extends  from  the  retina  to  the  point  of  union  of 
the  optic  nerves,  is  blind.  Still  the  right  optic  nerve,  dividing  at 
the  point  of  decussation  into  two  portions,  one  to  the  right  and  the 
other  to  the  left  side  of  the  brain,  is  in  communication  with  both 
nerves  of  the  third  pair,  so  that  although  the  pupil  of  the  diseased 
eye  becomes  expanded  and  fixed  when  the  sound  eye  is  kept  shut, 
it  instantly  contracts  when  this  eye  is  exposed  to  light,  and  so  long 
as  this  is  the  case,  performs  exactly  the  same  motions.  This  view 
of  the  matter  appears  to  be  confirmed  by  what  1  lately  observed  in 
a  patient  at  the  Eye  Infirmary,  in  whom  the  retina,  in  consequence 
of  an  injury  of  the  eye  received  some  years  before,  was  thickened, 
opaque,  and  separated  from  its  natural  adhesion  to  the  choroid. 
The  lens  lay  in  the  anterior  chamber,  and  was  removed  by  extrac- 
tion, but  the  eye  remained  perfectly  insensible  to  light.  When  the 
diseased  eye  was  separately  exposed  to  light,  its  pupil  stood  fixed 
and  dilated ;  but  when  both  were  exposed,  the  pupil  of  the  am- 
aurotic eye  moved  briskly.  We  had  no  reason  to  believe  that,  in 
this  case,  there  was  any  other  part  diseased  but  the  retina. 

Besides  the  motions  of  the  iris,  which  of  course  must  be  exam- 
ined, as  has  been  already  mentioned,  in  each  eye  separately,  and 
with  the  opposite  eye  excluded  from  light,  there  are  various  other 
particulars  respecting  the  iris,  wdiich  deserve  attention  ;  especially, 
the  form  and  situation  of  the  pupil,  and  the  inclination  of  the  iris, 
for  sometimes  the  pupil  is  very  irregularly  dilated,  at  other  times  it 
has  evidently  shifted  from  its  natural  place  towards  one  or  other 
part  of  the  circumference  of  the  iris,  while  this  membrane  itself  is 
in  some  cases  observed  to  be  bulging  towards  the  cornea,  and  in 
others  to  have  sunk  back,  so  as  to  present  anteriorly  a  concave  or 
funnel-like  form. 

4.  A  point  of  great  importance  in  every  case  of  amaurosis  is  the 
appearance  of  the  humours.  In  some  instances,  when,  for  exam- 
ple, the  disease  is  hydrocephalic,  and  occurs  in  a  young  subject, 
the  pupil  presents  its  natural  black  hue,  but  in  elderly  subjects,  it 
is  rarely  the  case  that  some  degree  of  glaucoma  does  not  accora- 

*  Travers's  Synopsis  of  the  Diseases  of  the  Eye,  p.  188.     Lond.  1820. 


647 

pany  amaurosis.  Such  a  complication  must,  of  course,  render  the 
prognosis  more  vmfavourable ;  although,  at  the  same  time,  it  must 
be  confessed,  that  some  of  the  most  hopeless  cases  of  amaurosis  are 
attended  with  a  perfectly  healthy  state  of  the  humours. 

5.  It  is  proper  to  observe,  whether  there  be  any  cicatrices  about 
the  face  or  head  of  amaurotic  patients,  marking  the  previous  occur- 
rence of  such  injuries  as  may  either  have  affected  the  branches  of 
the  fifth  pair  distributed  externally,  and  through  them  the  optic 
apparatus  within  the  cranium,  or  more  directly  have  induced  cere- 
bral effusions,  or  morbid  formations.* 

6.  The  general  aspect  and  bodily  constitution  must  be  regarded 
with  attention.  We  find  all  sorts  of  persons  amongst  the  amau- 
rotic ;  from  him  whose  vessels  seem  on  the  point  of  bursting  with 
plethora,  and  who  has  long  revelled  in  the  solid  luxuries  of  the 
table,  down  to  the  emaciated  victim  of  famine  and  habitual  intoxi- 
cation ;  all  ages,  all  ranks,  and  professions;  and  not  unfrequently 
it  happens,  that  by  directing  our  attention  to  the  history  of  the  in- 
dividual's previous  mode  of  life,  his  pursuits,  and  his  habits,  we 
are  enabled  to  detect  the  circumstances  which  have  been  the  ex- 
citing causes  of  his  complaint,  and  by  the  careful  avoidance  of 
which,  for  the  future,  the  cure  may  be  greatly  promoted. 

//.  Subjective  symptoms.  1.  The  most  important  of  these  is 
impaired  vision.  The  progress  of  this  symptom,  and  the  degree  it 
attains,  vary  in  different  cases  ;  for  in  some  instances  the  patient 
becomes  suddenly  and  permanently  bhnd,  while,  in  others,  the 
sight  fails  gradually  during  months  or  years,  without  ever  termi- 
nating in  total  loss  of  sight.  Hence  the  distinctions  of  sudden 
and  slow,  complete  and  incomplete  amaurosis. 

In  the  commencement  of  this  disease,  it  often  happens  that  the 
failure  of  sight  is  observed  only  occasionally,  occurring,  perhaps, 
but  seldom,  and  only  for  a  short  time,t  assuming  the  form  of  night- 
blindness  or  of  day-blindness,  or  coming  on  regularly  after  any 
continued  exertion  of  the  eyes  in  the  perception  of  minute  or  lu- 
minous objects.  Many  an  amaurotic  patient  can  read  with  ease  a 
few  lines  of  a  printed  book,  after  which  the  letters  appear  so  con- 
fused, and  the  effort  to  see  them  is  so  painful,  that  he  is  obliged 
to  desist.  Sudden  and  temporary  attacks  of  blindness  are  often 
connected  with  gastric  derangement,  and  are  entirely  removed  by 
correcting  the  state  of  the  digestive  organs ;  but  it  must  also  be 
confessed,  that  such  transient  attacks  are  sometimes  the  effect  of 
incipient  diseases  in  the  brain,  of  the  most  formidable  kind. 

The  failure  of  sight,  in  some  cases,  extends  to  the  whole  field 
of  view,  and  in  others  is  only  partial.  On  attempting  to  read,  for 
example,  more  or  less  of  the  page  appears  indistinct.  Perhaps 
the  patient  loses  sight  of  a  word  only  here  and  there,*  or  he  sees 
only  one-half  of  the  page,  while  the  other  half  is  as  if  hid  from  his 

*  See  pages  3  and  103.  t  Amaurosis  vaga.  t  Visus  interruptus. 


64S 

view.*  It  not  unfrequently  happens  that  an  amaurotic  eye  will 
still  discern  certain  objects,  if  they  are  placed  in  one  particular  di- 
rection ;  t  but  if  by  the  slightest  movement  of  the  eye  or  head,  the 
person  once  loses  sight  of  the  object,  he  finds  that  he  cannot  easily 
recover  the  same  point  of  vision.  Some  amaurotic  patients  see  all 
objects  disfigured,  crooked,  mutilated,  lengthened  or  shortened,  and, 
it  is  said,  even  inverted.^  The  flame  of  a  candle  sometimes  appears 
very  long  to  such  patients,  and  as  if  separated  into  several  portions ; 
a  symptom,  which  Beer  considered  indicative  of  disease  within  the 
cranium. 

The  failure  of  sight  in  amaurosis  occasionally  assumes  some- 
what of  a  myopic  or  a  presbyopic  form.  I  have  known  a  con- 
firmed amaurotic  patient  see  large  objects  with  considerable  dis- 
tinctness, through  a  double  concave  glass  of  12  inches  focus  ;  and 
another,  who  totally  bhnd  in  the  right  eye,  and  with  the  left  fast 
hastening  to  the  same  state,  could  still  with  the  latter  read  an  or- 
dinary type,  by  the  aid  of  a  double  convex  glass  of  7  inches  focus. 

2.  Intimately  connected  with  the  failure  of  sight  in  amaurosis, 
are  the  various  false  impressions  of  which  the  patients  complain  ; 
for  although  some  maintain,  that  they  have  no  sensation  of  any 
thing  intervening  between  them  and  objects,  and  are  not  distressed 
by  any  sort  of  spectra,  yet,  in  general,  amaurosis  is  more  or  less 
attended  by  the  disorders  described  in  the  preceding  chapter  under 
the  heads  of  photopsia,  onusccB  volitantes,  chriipsia,  and  acci- 
dental colours.  Photopsia,  in  particular,  is  apt  to  occur  at  the 
commencement  of  this  disease  in  plethoric  individuals,  and  muscse 
volitantes  in  dyspeptic  subjects.  Double  vision  is  a  very  common 
symptom.  As  the  disease  advances,  the  field  of  vision  seems  to 
become  obscured  by  a  universal  cloud, §  or  net  work, II  the  latter 
generally  appearing  grey  or  black,  especially  in  a  good  light,  or 
over  any  white  substance,  but  sometimes  becoming  luminous  in 
the  dark,  and  assuming  a  blueish  white  cdour,  like  silver,  or  red- 
dish yellow,  like  gold. 

3.  The  feehngs  of  the  patient  with  regard  to  hght  deserve  at- 
tention ;  for  sometimes  the  early  stages  of  amaurosis  are  accompa- 
nied by  an  unwonted  sensibility  to  light,  and  even  pain  on  expo- 
sure to  its  influence,  while,  in  other  cases,  there  are  from  the  very 
beginning,  a  diminished  sensibility  of  the  retina,  and  a  constant 
desire  on  the  part  of  the  patient  for  a  more  copious  illumination 
of  all  objects — a  thirst  for  light,  as  it  has  been  sometimes  called. 

4.  An  unwonted  dryness  of  the  eyes  and  nostrils  is  by  no  means 
an  uncommon  symptom  in  amaurosis  ;  and  it  is  observed,  that,  in 
general,  great  benefit  is  obtained,  in  such  cases,  if  a  restoration  is 
once  obtained  of  the  secretions  of  the  lachrymal  gland,  conjunctiva, 
and  Schneiderian  membrane. 

*  Hemiopia.  t  Visus  obliquus.  t  Visus  defiguratus. 

§  Visus  nebulosus.  II  Visus  reticulatus. 


649 

5.  Pain  in  the  eyes,  and  still  more  frequently  in  the  head  and 
face,  forms  one  of  the  most  important  symptoms  in  cases  of  amau- 
rosis. The  seat,  extent,  and  natm^e  of  the  pain  are  to  be  carefully 
investigated.  It  is  necessary  to  inquire,  whether  it  is  general  over 
the  head,  or  confined  to  one  particular  spot,  whether  it  is  attended 
by  throbbing,  relieved  or  aggravated  by  the  horizontal  position, 
increased  during  the  night,  affected  much  by  temperature,  exercise, 
or  diet,  and  whether  it  is  constant,  intermittent,  or  periodic.  It  is 
also  important  to  ascertain  whether  the  pain  is  accompanied  by 
vertigo,  tinnitus  aurium,  nausea,  a  tendency  to  coma,  sleepless- 
ness, inability  to  exert  certain  of  the  mental  faculties,  and  the  like. 

6.  The  general  health,  and  the  previous  diseases  of  the  individu- 
al, are  worthy  of  serious  consideration.  Is  the  constitution  stru- 
mous? Has  the  person  suffered  from  venereal  complaints,  or  long- 
continued  courses  of  medicine  for  the  cure  of  syphilis  ?  Had  he 
ever  typhus-fever  'l  Has  he  had  any  apoplectic,  epileptic,  or  para- 
lytic affection  ?  Has  he  been  subject  to  hypochondriasis,  or  if  the 
patient  be  a  female,  to  hysteria ')  Has  he  had  gout  or  rheuma- 
tism ?  What  has  been  the  condition  of  the  digestive  organs  ?  If 
the  patient  be  a  female,  what  has  been  the  state  of  the  uterine  sys- 
tem ?  Tliese,  and  many  other  points,  which  will  naturally  suggest 
themselves  to  the  mind  of  the  attentive  observer,  ought  to  be  made 
the  subjects  of  deliberate  inquiry. 

V.  Stages  and  degrees.  It  is  proper  to  distinguish  incipient 
from  confirmed  amaurosis ;  and  incomplete  from  complete. 

In  the  incipient  stage,  the  disease  is  only  developing  itself,  the 
patient,  in  general,  is  not  completely  deprived  of  sight,  remedies 
will  almost  always  be  useful  in  checking  the  progress  of  the  com- 
plaint, and  in  many  cases  a  perfect  cure  will  be  accomplished.  It 
sometimes  happens,  however,  that  even  from  the  very  first,  the 
blindness  is  complete,  and  the  case  incurable.  In  the  co?ifirmed, 
or  inveterate  stage,  remedies  may  perhaps  relieve  some  of  the  at- 
tending symptoms,  but  will  very  seldom  effect  a  cure.  The  patient, 
however,  is  not  always  totally  deprived  of  sight,  even  in  confirmed 
cases  of  long  standing ;  but  often  retains  a  perception  of  light  and 
shadow,  or  a  certain  degree  of  capability  to  discern  different  grada- 
tions of  light,  certain  colours,  and  even  objects  well  illuminated  or 
strongly  contrasted. 

In  complete  amaurosis,  the  patient  is  unable  to  distinguish 
any  object  or  colour  whatever,  and  is  often  insensible  even  to  the 
presence  of  light.     Any  degree  less  than  this  is  incomplete. 

VI.  Diagnosis.  It  is  chiefly  with  incipient  cataract  that  amau- 
rosis is  apt  to  be  confounded.  On  this  subject,  I  must  refer  to  what 
has  been  said  at  page  472. 

Glaucoma  is  often  mistaken  for  amaurosis,  from  the  circumstance 

of  being  always  attended  by  some  of  the  subjective  symptoms  of 

'this  disease ;  but  the  objective  symptoms  of  glaucoma,  such  as  the 

apparent  greenness  of  the  humours,  and  the  hardness  of  the  eye- 

82 


650 

ball,  are  sufficiently  remarkable,  to  enable  us,  in  general,  to  distin- 
guish it  from  simple  amaurosis.  The  complication,  however,  of 
amaurosis  with  glaucoma  is  extremely  common.  Amaurosis  also 
occurs  in  combination  with  cataract ;  and  in  this  case,  glaucoma  is 
generally  superadded. 

VII.  Prog7iosis.  There  is  scarcely  any  disease  in  which  the 
prognosis  is  on  the  whole  so  unfavourable  as  in  amaurosis.  When 
the  complaint,  indeed,  is  recent,  its  cause  evident,  and  the  subject 
under  middle  life,  a  complete  cure  is  not  unfrequently  obtained. 
This  is  sometimes  the  case  even  when  the  loss  of  sight  is  total. 
Much  more  frequently  a  partial  amelioration  only  is  effected  ;  the 
disease  being  checked,  and  a  certain  share  of  vision  preserved.  In 
confirmed  cases,  it  rarely  happens  that  much  improvement  takes 
place,  even  under  the  best  directed  treatment. 

A  sudden  amaurosis  is  generally  less  unfavourable  than  one 
which  has  developed  itself  slowly.  When  the  pupil  is  only  slightly 
dilated,  still  movable,  and  of  its  natural  form,  the  consistence  of 
the  eyeball  neither  firmer  nor  softer  than  in  health,  and  no  glau- 
coma present,  we  may  pronounce  a  more  favourable  prognosis  than 
when  the  pupil  is  fixed  in  the  state  either  of  expansion  or  contrac- 
tion, the  eyeball  either  boggy  or  of  preternatural  hardness,  or  the 
bottom  of  the  ey&  presenting  a  greenish  opacity.  If  the  attack  has 
been  sudden,  a  want  of  power  in  the  muscles  of  the  eyeball  or  eye- 
lids, along  with  the  proper  amaurotic  symptoms,  may  be  regarded 
as  a  sign,  that  the  cause  of  the  disease  is  some  general  pressure 
within  the  cranium,  which  energetic  measures  will  probably  re- 
move ;  whereas  the  slow  succession  of  one  amaurotic  and  paralytic 
symptom  after  another  is  more  likely  to  arise  from  the  growth  of 
some  incurable  tumour  or  exostosis. 

VIII.  Treatment.  It  is  evident,  that  in  the  treatment  of  any 
amaurotic  affection,  it  should  be  our  first  object,  to  discover  the 
cause  or  causes  upon  which  it  depends,  and  then  to  attack  these 
by  appropriate  remedies.  As  the  causes  are  very  various,  and  even 
opposite,  so  must  also  be  the  means  of  cure.  We  may  arrange 
them  in  two  classes,  general  and  local. 

I.  General  Means.  1.  Depletion.  When  we  find  that  an  am- 
aurotic attack  is  attended  by  signs  of  a  determination  of  blood  to 
the  head,  such  as  headach,  vertigo,  flushed  countenance,  and  arte- 
rial throbbing  of  the  temples  ;  that  the  pulse  is  full,  and  the  subject 
young  or  plethoric,  we  will  of  course  employ  general  and  topical 
blood-letting,  purge  the  patient,  and  put  him  on  low  diet.  If  the 
case  is  purely  one  of  pressure  on  the  brain,  from  vascular  disten- 
tion, these  means,  conjoined  with  rest,  will  probably  effect  a  cure. 
If  along  with  vascular  pressure,  there  is  effusion,  or  even  some 
morbid  formation  within  the  cranium,  still  depletion  will  afford  to 
a  plethoric  subject  the  most  effectual  palliative  relief,  and  act  as  the 
best  preparative  for  other  remedies,  especially  for  the  use  of  mer- 
cury.    It  is  impossible  to  lay  down  any  general  rule  regarding  the 


651 

point  to  which  the  bleeding  and  purging  plan  is  to  be  carried  in 
the  treatment  of  amaurosis  with  plethora.  We  must  equally  be- 
ware of  stopping  short  before  our  purpose  is  obtained,  and  the 
balance  of  the  circulation  restored,  and  of  pushing  the  depletion  so 
far  that  it  becomes  merely  a  means  of  weakening  the  patient,  with- 
out promoting  the  cure. 

2.  Mercury  has  long  and  justly  maintained  a  high  character 
as  a  remedy  in  amaurosis.*  It  is  probable  that  it  aids  in  the  cure 
of  this  disease  chiefly  as  a  sorbefacient,  promoting,  in  particular, 
the  removal  of  effusions  within  the  cranium,  and  sometimes  even 
of  morbid  formations.  It  cannot  be  doubted,  that  many  of  the 
disordered  states  of  the  internal  optic  apparatus,  which  end  in  am- 
aurosis, are  originally  of  an  inflammatory  nature  ;  chronic  inflam- 
mation of  the  optic  nerve,  and  of  the  retina  may  sometimes  be  the 
cause  of  this  disease,  and  in  all  such  cases,  there  is  reason  to  be- 
lieve, from  what  we  know  of  the  beneficial  effects  of  mercury  in 
other  inflammatory  affections  of  the  organ  of  vision,  that  this  medi- 
cine will  prove  more  serviceable  than  almost  any  other  remedy. 
There  are,  of  course,  cases  of  amaurosis,  in  which  from  the  sunken 
state  of  the  patient's  constitution,  it  might  prove  injurious  to  employ 
mercury ;  neither  will  it  always  be  necessary  or  proper,  in  those 
cases  in  which  we  judge  it  right  to  try  this  remedy,  to  salivate  the 
patient,  although  in  some,  salivation  only  will  effect  a  cure.  Mr. 
Travers,  speaking  of  mercury  in  amaurosis,  says,  "I  have  been 
witness  to  its  power  in  suddenly  arresting  the  disease  in  too  many 
instances,  not  to  entertain  a  far  higher  opinion  of  it  than  of  any 
other  article  of  the  materia  medica."t  Mr.  Lawrence's  testimony 
is  not  less  explicit.  "  We  must  have  recourse,"  says  he,  "  to  mer- 
cury, which  appears  to  be  as  decidedly  beneficial  in  these  cases  as 
in  iritis,  or  general  internal  inflammation."  "  When  the  antiphlo- 
gistic treatment,"  he  adds,  "  and  a  fair  trial  of  mercury  have  failed, 
I  do  not  know  that  it  is  possible  to  effect  any  further  essential  good 
by  other  means,"! 

3.  Emetics  and  Nauseants.  That  emetics  must  be  useful  in 
cases  of  amaurosis  depending  on  gastric  derangement,  and  that 
nauseants  may  sometimes  prove  serviceable,  appears  highly  proba- 
ble. Accordingly  we  find,  that  in  recent  incomplete  amaurosis, 
arising  from  irritation  in  the  digestive  organs,  Schmucker,  §  Rich- 
ter,  II  and  Scarpa  1  derived  the  best  effects  from  the  emetic  plan  of 
cure ;  and  although  Beer,  and  several  later  observers,  have  been 
less  successful  in  its  employment,  it  still  deserves  attention.  That 
it  is  not  calculated,  more  than  any  other  means  of  cure,  for  gen- 
eral adoption,  and  that,  in  some  cases,  it  might  even  prove  decidedly 

*  Heister  de  Cataracta,  Glaucomate,  et  Amaurosi,  p.  331.     Altorfi,  1713. 

t  Synopsis  of  the  Diseases  of  the  Eye,  p.  305.     London,  1820. 

t  Lectures  in  the  Lancet,  Vol.  x.  p.  578.     London,  1826. 

§  Vermischte  Chirurgische  Schriften,  Vol.  ii.  p.  3.     Berlin,  1786. 

11  AnfangsgrUndet  der  Wundarzneykuns,  Vol.  iii.  p.  443.     Gottingen,  1804. 

•S  Trattato  delle  Malattie  degli  Occhi,  Vol.  ii.  pp.  227,  230.     Pavia,  1816, 


652 

hurtful,  can  form  no  objection  to  its  use,  where  the  tongue  is  foul, 
the  mouth  bitter,  the  hypochondria  distended,  the  stomach  loaded 
with  indigested  food,  and  the  patient  complaining  of  continual 
nausea,  without  being  either  greatly  debilitated,  or,  on  the  other 
hand,  plethoric,  and  incUned  to  cerebral  congestion. 

The  following  is  the  emetic  plan,  as  laid  down  by  Scarpa.  For 
an  adult,  dissolve  three  grains  of  tartarised  antimony  in  four  ounces 
of  water,  of  which  give  two  table-spoonfuls  every  half  hour,  till  it 
produces  nausea  and  copious  vomiting.  Next  day  the  patient  is  to 
begin  the  use  of  a  resolvent  powder,  composed  of  one  ounce  of 
cream  of  tartar,  with  one  grain  of  tartarised  antimony,  divided  into 
six  equal  parts,  of  which  one  is  to  be  taken  in  the  morning,  another 
four  hours  after,  and  a  third  in  the  evening ;  and  this  to  be  repeat- 
ed during  eight  or  ten  successive  days.  The  effects  will  be  slight 
nausea,  purging,  and  perhaps  vomiting.  If,  during  the  use  of  the 
resolvent  powder,  the  patient  is  troubled  with  ineffectual  efforts  to 
vomit,  want  of  appetite,  (fee.  without  any  amendment  in  vision, 
the  emetic  is  to  be  repeated  ;  and  even  a  third  and  fourth  time,  if 
it  seems  necessary.  The  stomach  being  by  these  means  cleared, 
the  patient  is  to  begin  the  use  of  the  resolvent  pills  of  Schmucker,* 
or  of  Richter.t 

Scarpa  states  the  following  to  be  the  consequences  usually  ob- 
served to  result  from  this  treatment.  The  patient,  after  having 
vomited  copiously,  feels  more  easy  and  comfortable.  Sometimes 
on  the  same  day  on  which  he  has  taken  the  emetic,  he  begins  to 
distinguish  surrounding  objects  ;  in  other  cases,  this  advantage  is 
not  obtained  till  the  fifth,  seventh,  or  tenth  day  ;  and  in  others,  not 
till  some  weeks  after  the  uninterrupted  use  of  the  resolvent  pow- 
ders or  pills.  The  cure  is  seldom  effected  in  less  than  a  month, 
and  is  aided  by  such  local  remedies  as  are  calculated  to  excite  the 
languid  action  of  the  nerves  of  the  eye. 

4.  Evacuants,  of  different  sorts,  besides  those  already  mentioned, 
are  required  in  the  treatment  of  certain  varieties  of  amaurosis  ;  such 
as  emmenagogues,  when  the  disease  appears  to  be  connected  with 
impeded  menstruation  ;  anthelmintics,  when  it  arises  from  worms ; 
diaphoretics,  when  suppressed  perspiration  is  the  cause. 

5.  Tonics,  such  as  cinchona,  and  the  preparations  of  iron,  form  a 
class  of  medicines  of  great  importance  in  the  treatment  of  amau- 
rosis. That  this  disease,  in  many  instances,  takes  its  origin  in 
vascular  exhaustion  and  nervous  debility,  and  is  corrected,  or  en- 
tirely removed,  by  the  use  of  a  nourishing  diet,  the  cold  bath,  tonic 

*  R  Gummi-resinaB  Sagapeni,  Gummi-resinEe  Bubonis  Galbani,  Saponis  Veneti, 
aa  5i-  Rhei  optimi  S^ss.  Tartratis  Antimonii,  gr.  xvi.  Sued  Liquiritise  Si- 
Fiat  massa,  in  pilulas  formanda,  singulas  granum  i  pendentes.  Fifteen  to  be  taken 
morning  and  evening,  for  a  month  or  six  weeks. 

t  ft  Gummi-resinEe  Ammoniaci,  Gummi-resinsB  Asssefoetidae,  Saponis  Veneti, 
Radicis  Valerianae  subtillissime  pulverisats,  Summitatum  Arnicse,  aa  5ii-  Tartratis 
Antimonii  gr.  xviij.  Fiat  massa,  in  pilulas  formanda,  singulas  grana  ii  pendentes. 
Fifteen  to  be  taken  thrice  a-day,  for  some  weeks. 


653 

medicines,  and  influences  of  a  similar  sort,  must  be  well  known  to 
all  who  have  had  any  considerable  experience  in  the  treatment  of 
eye-diseases,  and  whose  opinions  are  not  warped  by  some  particu- 
lar hypothesis,  which  leads  them  perhaps  to  regard  amaurosis  as 
always  depending  on  one  kind  of  cause,  and  therefore  to  be  cured 
only  by  one  plan  of  treatment.  It  cannot  be  denied,  that  tonics 
would,  in  many  cases,  do  harm,  just  as  bleeding,  purging,  vomit- 
ing, or  the  use  of  mercury  would  do,  if  misapplied  ;  but  this  is  no 
reason  why  they  should  be  indiscriminately  rejected. 

6.  Stimulants.  Many  and  various  internal  stimulants  have 
been  employed  in  the  treatment  of  amaurosis  ;  most  of  them  quite 
empirically,  or  on  some  vague  idea  of  their  possessing  a  power  of 
rousing  the  sunken  sensibihty  of  the  nerves  ;  others,  again,  on  the 
ground  of  their  evidently  exciting  violent  convulsions,  which,  of 
course,  they  are  enabled  to  do  only  through  the  instrumentality  of 
the  nervous  system.  Camphor  and  nux  vomica  may  be  mentioned, 
as  examples  of  this  class  of  remedies  for  amaurosis.  It  is  well 
known  to  toxicologists,  that  those  substances,  given  in  considerable 
doses,  excite  violent  tetanic  paroxysms,  not  only  in  the  parts  an- 
imated by  the  spinal  nerves,  but  also  in  the  muscles  of  the  face, 
eyes,  and  eyelids.  In  the  hope,  perhaps,  that  they  might  also  pro- 
duce a  stimulating  effect  on  the  nerves  of  sense,  these  substances, 
and  especially  strychnia,  the  alkaloid  contained  in  nux  vomica, 
and  one  of  the  most  energetic  of  poisons,  have  been  applied  in  va- 
rious modes  for  the  cure  of  amaurosis.  Arnica  montana,  hellebo- 
rus  niger,  naphtha,  phosphorus,  and  a  host  of  other  drugs,  of  simi- 
lar properties,  have  been  employed  on  the  same  principle  ;  but  it  is 
extremely  doubtful  if  they  have  been  productive  of  the  least  good 
effect. 

7.  Antispasmodics^  as  opium,  musk,  valerian,  and  the  like,  have 
occasionally  been  used  in  the  treatment  of  amaurosis,  especially 
when  this  disease  has  been  connected  with  epilepsy. 

8.  Sedatives^  as  belladonna,  hyosciamus,  and  aconitum,  have 
been  tried  ;  and  I  have  known  ihe  first  mentioned  of  these  useful, 
in  cases  where  the  amaurotic  symptonjs  were  attended  with  ner- 
vous pain,  affecting  the  branches  of  the  fifth  pair. 

11.  Local  Means.  1.  Coimier-irnVa^iow,  excited  by  rubefacient 
liniments,  tartar-emetic  ointment,  blisters,  and  issues,  proves  high- 
ly useful  in  almost  every  variety  of  amaurosis.  A  succession  of 
blisters  over  the  head  is  perhaps  the  most  efficient  mode  of  employ- 
ing counter-irritation  ;  but  much  advantage  is  also  derived  from 
stimulating  friction  of  the  forehead  and  temples,  blisters  behind 
the  ears,  or  to  the  nape  of  the  neck,  caustic  issues  in  the  same 
place,  or  behind  the  angle  of  the  jaw,  a  tartar  emetic  eruption  be- 
tween the  shoulders,  and  sometimes  even  by  still  more  remote 
applications  of  the  same  sort,  as  the  immersion  of  the  feet  in  warm 
water,  holding  in  suspension  a  quantity  of  powdered  mustard. 

2.  Sternutatories  have  been  used  with  some  advantage,  espe- 


654 

cially  in  cases  where  the  mucous  secretion  from  the  conjunctiva, 
and  Schneiderian  membrane  appeared  to  be  partially  suppressed. 
Mr.  Ware  has  published  *  a  considerable  number  of  cases,  in  which 
the  chief  means  of  cure  was  a  mercurial  snuff.  He  recommends 
one  grain  of  turpeth  mineral  to  be  mixed  with  twenty  grains  of 
powder  of  liquorice,  and  about  a  fourth  of  this  to  be  snuffed  up  the 
nose  two  or  three  times  a-day.  In  cases  where  the  nostrils  are 
particularly  dry,  the  patient  may  promote  the  efficacy  of  the  ster- 
nutatory, by  previously  inhaling  the  steam  of  warm  w-ater  through 
the  nostrils. 

5.  Stimulating  vapours,  directed  against  the  eyes,  liave  been 
recommended,  especially  in  cases  where  there  are  evident  signs  of 
great  local  debility,  without  any  appearances  of  congestion  or  ple- 
thora. A  little  sulphuric  ether,  or  aqua  ammoniae,  may  be  poured 
into  the  palm  of  the  hand,  and  held  under  the  eyes  till  the  fluid 
has  evaporated  ;  and  this  may  be  repeated  several  times  daily. 

4.  Electricity  formerly  enjoyed  a  considerable  reputation  as  a 
remedy  in  amaurosis,  but  of  late  years  has  been  almost  entirely 
neglected.  As  it  is  not  likely  to  be  trusted  to,  nor  even  tried,  where 
the  disease  is  recent,  it  is  not  to  be  wondered  at  that  it  should, 
hke  every  other  kind  of  remedy,  prove  totally  inert  in  a  great  ma- 
jority of  the  confirmed  or  inveterate  cases,  which,  as  to  a  last  re- 
source, may  be  submitted  to  its  influence.  The  cases  related  by 
Mr.  Hey  t  and  Mr.  Ware,+  afford  sufficient  ground  for  believing 
that  electricity  may  occasionally  prove  highly  serviceable  in  the 
treatment  of  this  disease.  Mr.  Ware  considers  it  more  useful  in 
amaurosis  arising  from  the  effect  of  lightning  on  the  eyes,  than  in 
any  other  variety  of  the  complaint.  The  mode  of  application  is 
chiefly  by  directing  the  electric  aura  against  the  eyes,  diawing  it 
from  them  during  the  insulation  of  the  patient,  and  sometimes  by 
taking  small  sparks  from  the  eyelids  and  integuments  round  the 
orbits. 

The  general  review  which  we  have  thus  taken  of  the  seat, 
causes,  symptoms,  and  treatment  of  amaurosis,  is  sufficient  to  show 
that  this  subject  is  surrounded  with  difficulties,  and  that  there  is  a 
necessity  for  exercising  the  most  minute  and  careful  observation, 
if  we  hope  to  make  any  advancement  in  the  knowledge  of  this 
class  of  diseases.  Each  individual  case  of  amaurosis,  to  do  it  jus- 
tice, would  require  to  be  considered  at  leisure,  and  in  all  its  bear- 
ings— to  be  made,  in  fact,  a  subject  for  study.  It  is  but  too  evi- 
dent, that  many  who  have  written  upon  amaurosis,  labouring 
probably  under  a  distaste  for  what  they  had  found  to  be  an  irksome 
task,  namely,  the  investigation  of  complicated  phenomena,  have 

*  Observations  on  the  Cataract  and  Gutta  Serena,  pp.  407,  410,  417,  &c.  Lon- 
don, 1812. 

t  Medical  Observations  and  Inquiries,  Vol.  v.  p.  1.     London,  1776. 

t  Observations  on  the  Cataract  and  Gutta  Serena,  pp.  379,  381,  &c.  London, 
1813. 


655 

endeavoured  to  cut  the  matter  short,  and  introduce,  into  a  subject 
which  does  not  admit  of  it,  some  easy  simple  arrangement  of  their 
own.  FeeUng  themselves,  as  well  they  might,  unable  to  embrace 
the  infinite  diversities  of  this  class  of  diseases,  they  have  endea- 
voured to  reduce  the  phenomena  of  amaurosis  to  their  own  con- 
tracted notions,  and  satisfying  themselves  with  a  few  artificial  dis- 
tinctions, have  actually  discouraged  the  attempt  to  follow  nature 
with  that  perseverance,  without  which,  in  a  subject  like  this,  no 
real  progress  can  be  made. 


SECTION  II. CLASSIFICATIONS  OF  THE  AMAUROSES. 

Some  will  have  no  classification  ;  but  insist  that  amaurosis  is 
always  one  and  the  same.  Others  have  adopted  the  division,  al- 
ready noticed,  into  functional  and  organic,  whereas  every  case  of 
amaurosis  is  both.  Beer  has  classified  the  different  species  accord- 
ing to  their  symptoms ;  and  it  may  not  be  improper  to  examine 
his  classification  somewhat  more  particularly.  The  principle  is 
evidently  good  ;  determining  the  seat  and  natu)e  of  the  disease,  by 
the  particular  symptoms  present. 

Beer  admits  four  classes  :  the^rs^  including  amaurosis,  character- 
ized only  by  subjective  symptoms,  or,  in  other  words,  by  impaired 
vision,  without  any  diseased  appearances  about  the  eye ;  the  second, 
amaurosis  characterized  not  only  by  impaired  vision,  but  by 
changes  in  the  texture  of  some  part  of  the  optic  apparatus ;  the 
third,  amaurosis  characterized  by  impaired  vision,  with  changes  in 
the  form  and  activity  of  some  part  of  the  optic  apparatus  ;  and  the 
fourth^  amaurosis  in  which  the  characteristics  of  the  first  three 
classes  are  combined. 

It  does  not  admit  of  denial,  that  we  occasionally  meet  in  nature 
with  cases  of  amaurosis,  presenting  such  differences  in  the  symp- 
toms, as  Beer  has  chosen  for  the  ground-work  of  his  classification. 
For  instance,  it  sometimes  happens  that  in  the  amaurosis  from  ex- 
haustion, there  is  scarcely  an  objective  symptom  to  be  discovered 
about  the  eye,  and  we  are  obliged  to  admit  the  existence  of  the  dis- 
ease almost  solely  on  the  testimony  of  the  patient,  the  case  evident- 
ly falling  within  Beer's  first  class.  We  may  admit,  also,  the  only 
instance  which  Beer  has  introduced  into  his  second  class,  to  be  a 
correct  example  of  amaurosis,  characterized  by  loss  of  vision,  with 
change  in  texture  ;  namely,  that  variety  of  the  disease,  which  re- 
sults from  absorption  of  the  choroid  pigment.  In  like  manner  hy- 
drocephaUc  amaurosis  very  frequently  presents  no  other  symptoms 
than  loss  of  pight,  and  fixed  dilated  pupil,  so  that  it  is  referrable  to 
Beer's  third  class.  Amaurosis,  again,  from  an  injury  of  the  eye,  is 
often  attended,  in  addition  to  loss  of  sight,  by  irregular  immovable 
pupil,  laceration  of  the  tunics,  and  enlargement,  or,  on  the  contrary. 


656 

atrophy  of  the  eyeball.  Such  a  case  will  undoubtedly  belong  to 
the  fourth  class.  I  trust,  however,  that  I  shall  not  be  accussed  of 
rashness,  nor  of  disrespect  for  the  labours  of  Professor  Beer,  when  I 
state  my  belief,  that  the  cases  arranged  under  his  four  classes,  are 
not  uniformly  attended  by  the  symptoms  which  he  has  assigned 
to  them  ;  but  that  those  species  of  amaurosis,  which  he  has  set 
down  as  characterized  by  subjective  symptoms  only,  are  sometimes 
attended  by  objective  signs  also,  while,  on  the  other  hand,  those 
changes  in  the  texture  and  form  of  certain  parts  of  the  optic  appa- 
ratus, which  be  has  considered  as  characteristic  of  other  species, 
are  sometimes  merely  coincident,  and  not  essential.  The  amauro- 
sis, for  example,  which  originates  from  over-excitement  of  the  eye, 
or  from  plethora,  which  Beer  places  in  his  first  class,  is  often  at- 
tended by  fixed  dilated  pupil,  a  circumstance  which  should  assign 
it  a  place  in  the  third  class.  The  amaurosis  from  rage,  is  merely 
a  variety  of  the  plethoric  or  apoplectic,  and  may  or  may  not  present 
the  glaucomatous  appearance  of  the  humours,  on  account  of  which 
he  has  placed  it  in  his  fourth  class. 

Glaucoma,  one  of  the  changes  upon  which  Beer  has  founded  his 
classification,  is  by  no  means  an  essential  part  of  any  amaurosis. 
Neither  is  fixed  dilated  pupil  any  thing  more  than  a  frequent  coin- 
cidence. In  the  hydrocephalic  amaurosis,  for  instance,  the  pupil,, 
though  generally  expanded  and  motionless,  is  not  always  so ;  and 
it  nmst  evidently  form  an  insuperable  objection  to  any  classification 
founded  on  symptoms,  that  sometimes  they  are,^  and  at  other  times 
they  are  not  present. 

Beer  admits  as  species,  an  epileptic,  and  a  paralytic  amaurosis  ^ 
whereas  the  epilepsy  and  anmurosis  in  the  one  case^  and  the  palsy 
and  amaurosis  in  the  other,  ought  to  be  regarded  not  as  standing 
in  the  relation  of  cause  and  effect,  but  merely  as  coincident  effects^ 
arising  from  one  and  the  same  cause,  namely,  some  morbid  change 
or  formation  within  the  cranium. 

While  Beer's  classes  refer  to  the  appearances  presented  in  difier- 
ent  cases,  his  distinctions  of  species  are  founded,  in  general,  oi> 
the  causes,  efficient  or  remote,  of  the  disease ;  and  on  the  same 
basis,  I  believe,  we  ought  to  form  our  general  arrangement  of  the 
amauroses.  In  other  words,  we  ought  to  group  together  those 
species,  the  causes  of  which  bear  a  resemblance  to  each  other. 

The  following  is  a  list  of  some  of  the  principal  varieties  of  amau- 
rosis, arranged  according  to  their  causes.  It  would,,  no  doubt,  be 
desirable  to  have  a  classification,,  founded  on  the  efficient  causes 
only,  without  being  obliged  to  refer,  in  any  instance,  to  the  mere 
remote  or  exciting  causes.  But  this  does  not  appear  practicable,  on 
account  of  our  ignorance  of  the  mode  in  wliich  certain  remote  causes 
act. 

I.  Amaurosis  prom  Causes  directly  affecting  the. 
Retina, 


657 

1.  Pressure  on  the  concave  surface  of  the  retina ;  as  by  de- 
pressed lens,*  vitreous  dropsy ^\  (fee. 

2.  Pressure  on  the  convex  surface  of  the  retina  ;  as.  by  sub-scle- 
rotic dropsy, %  suh-choroid  dropsy, h  (fee. 

3.  Injuries  of  the  retina;  as,  in  blows  on  the  eye,\  penetrating 
wounds  of  the  eye, IF  &c. 

4.  Inflammation  affecting  the  choroid.**  the  retina,tt  or  both. 

5.  Ossification  of  the  choroid,  H  or  of  the  retina.§§ 

6.  Absorption  of  the  pigmentum  nigrum.  II II 

II.  Amaurosis  from  Disease  of  the  Optic  Nerve  with- 
in THE  Orbit,  or  from  Pressure  on  that  portion  of  the 
Optic  Nerve  ;  as  from  inflammation^^li  encysted  arid  other 
tumours,***  aneurisms, '\tt  exostosis,  XXX  (fee. 

III.  Amaurosis  from  Fractured  Cranium  with  De- 
pression. 

IV.  Amaurosis  from  Vascular  Pressure. 

1.  Cerebral  Plethora  and  Congestion. 

2.  Apoplexy. 

3.  Aneurismal  Dilatation  of  the  Cerebral  Arteries. 

V.  Amaurosis  from  Inflammation,  or  the  immediate 
consequences  of  Inflammation  of  the  Brain  or  its  Mem- 
branes, AND  especially  OF  THE  PARTS  FORMING  THE  OpTIC 

Apparatus. 

Amaurosis  may  be  the  consequence  either  of  the  first,  or  of  the 
second  stage  of  inflammation ;  and  in  the  latter  case,  one  or  other 
of  the  following  secondary  effects  of  inflammation  may  operate  as 
the  immediate  cause  of  the  amaurotic  affection ;  viz.  1.  Effusion 
of  Serum;  2.  Effusion  of  coagulable  lymph,  with  thickening  of 
the  membranes,  or  formation  of  false  membranes;  3.  Suppura- 
tion; 4.  Ramollissement ;  5.  Ulceration. 

The  following  are  some  of  the  exciting  causes  of  inflammation 
of  the  internal  optic  apparatus. 

1.  Intense  light. 

2.  Over-exercise  of  the  sight. 

3.  Concussion,  and  other  injuries  of  the  head. 

4.  Irritation  from  teething,  disordered  bowels,  (fee. ;  as,  in  the 
itiflammation  of  the  brain  in  children,  commonly  called  acute 
hydrocephalus. 

5.  Febrile  diseases ;  as,  continued  fever,  scarlatina^  measles, 


&.C. 

6. 

Passions  of  the  mind. 

7. 

Habitual  use  of  alcoholic  fluids. 

8. 

Insolation. 

> 

*  See  pp.  499  and  509.      t  See  p.  444. 

§  Ibid.                               11  See  p.  257. 

**  See  p.  380.                   t+  See  p.  386. 

§§  Ibid.                               III!  See  pp.  581  and  591. 

«*"  See  p.  220.                 ttt  See  pp.  240  and  247. 

83 

t  See  p.  442. 
ir  Ibid. 
«  Seep.  431. 
TTir  See  p.  213 
m  See  p.  37. 

658 

9.  Suppressed  evacuations ;  as,  of  the  menses^  hcBmorrhoids, 
milk,  matter  of  ulcer s^  mucus  in  catarrh,  <fec. 

10.  Suppressed  eruptions,  acute  or  chronic. 

11.  Cold,  and  suppressed  perspiration. 

12.  Fatigue. 

YI.  Amaurosis  from  Morbid  Changes  and  Formations 
WITHIN  THE  Cranium. 

1.  Morbid  changes  in  the  optic  nerve. 

2.  Morbid  formations  in  the  brain ;  as,  tubercles,  hydatids^ 
fungus  h(Bmatodes,  (fee. 

3.  Morbid  changes  in  the  membranes  or  bones  of  the  cranium ; 
as,  exostosis,  &,c. 

4.  Morbid  changes  affecting  the  fifth  pair  of  nerves. 

YII.  Amaurosis  from  the  Influence  of  Poisons  ;  as, 
alcohol,  opium',  tobacco,  belladonna,  hyosciamus,  &c. 

YIII.  Amaurosis  from  Inanition  or  Debility  ;  as,  from 
chronic  diarrhoea,  excessive  venery,  &c. 

IX.  Amaurosis  from  Local  Causes,  operating  sympa- 
thetically. 

1.  Diseases  of  the  lachrymal  organs.* 

2.  Wounds  of  the  branches  of  the  fifth  pair  of  nerves.t 

3.  Irritation  of  the  branches  of  the  fifth  pair  of  nerves. 

4.  Diseases  of  the  frontal  sinus.  I 

5.  Irritation  from  worms  in  the  intestines. 

6.  Acute  disorders  of  the  stomach. 

7.  Chronic  disorders  of  the  digestive  organs. 


section  III. — illustrations  of  some  of  the  species  of 

amaurosis. 

Those  species  of  amaurosis  to  which  references  are  attached  in 
the  foregoing  table,  have  already  been  considered,  and  do  not  re- 
quire to  be  again  brought  under  review.  There  are  several  others, 
which,  I  conceive,  it  would  be  out  of  place  to  consider  at  any  length 
in  a  treatise  on  the  diseases  of  the  eye,  because  the  amaurosis,  in 
the  cases  in  question,  is  merely  one  out  of  many  sj'^mptoms,  and 
rarely,  if  ever,  becomes  the  subject  of  separate  inquiry,  or  medical 
treatment.  In  the  present  section,  it  is  my  intention  to  add  a  few 
illustrations,  chiefly  of  those  species,  in  which  the  loss  of  sight 
forms,  not  so  much  a  merely  coincidental  symptom,  as  the  essential 
and  most  important  part  of  the  disease. 

I.  Amaurosis  from  Fractured  Cranium  with  Depression,  or 
from,  Sanguineous  Extravasation  in  consequence  of  Injury. 

The  insensibility  attendant  on  pressure  on  the  brain  from  these 
causes,  may  be  more  or  less  complete  ;  for  in  some  instances,  the 

*  See  p.  180.  t  See  p.  102.  %  See  p.  55. 


659 

patient  lies,  unconscious  indeed  of  what  is  passing  around  him, 
but  capable  of  being  roused  by  strong  impressions  on  his  senses ; 
while  in  other  cases  the  loss  of  sense  is  so  complete,  that  the  skin 
may  be  pinched,  a  lighted  candle  held  close  to  the  eye,  and  the 
loudest  sound  apphed  to  the  ear,  without  any  evident  effect. 

Where  the  cause  of  these  symptoms  is  simply  a  fractured  and 
depressed  portion  of  the  cranium,  they  show  themselves  immedi- 
ately after  the  infliction  of  the  injury  ;  but  where  they  depend  on 
extravasation  of  blood,  either  accompanying  fracture  or  indepen- 
dent of  it,  the  collection  of  blood  may  form  slowly,  and  a  consid- 
erable interval  of  time  elapse  before  the  patient  becomes  insensible. 

Mr.  Brodie  observes,*  that  "  it  sometimes  happens,  that  there  is 
a  destruction  of  sensibility  in  one  part  of  the  system,  while  the 
general  sensibility  is  impaired  only  in  a  slight  degree ; "  and  he 
illustrates  this  remark  by  the  following  instance,  in  which  the 
sensibility  of  the  optic  nerves  was  chiefly  affected. 

Case.  An  old  man,  who  had  been  run  over  by  a  cart,  was  ad- 
mitted into  St.  George's  Hospital.  There  was  a  fracture  with  de- 
pression of  one  of  the  parietal  bones.  He  was  sensible,  but  slow 
in  giving  answers,  and  peevish,  and  it  was  observed  that  he  was 
totally  bhnd.  Mr.  Gunning  removed  a  portion  of  the  parietal  bone 
with  the  trephine,  and  elevated  the  depression  ;  but  the  operation 
produced  no  change  in  the  symptoms.  About  thirty-six  hours  after 
the  accident,  the  pulse  became  frequent,  and  he  was  delirious. 
He  remained  entirely  deprived  of  the  faculty  of  vision  ;  believing 
that  he  saw  imaginary  objects,  but  totally  unconscious  of  the  ex- 
istence of  those  actually  before  his  eyes.  At  the  expiration  of  the 
fifth  day  he  died.  On  examining  the  body,  the  membranes  of  the 
brain  were  found  inflamed,  and  smeared  with  pus  and  lymph. 
In  the  basis  of  the  cranium  there  was  a  transverse  fracture  extend- 
ing across  the  sphenoid,  the  fractured  edges  being  displaced  in  such 
a  manner  as  to  press  on  the  optic  nerves  immediately  behind  the 
orbits,  and  to  explain,  in  the  most  satisfactory  manner,  the  total 
loss  of  sight. 

To  Mr.  Brodie  we  also  owe  the  following  interesting  observa- 
tions on  the  affections  of  the  pupils  in  cases  of  compression  of 
the  brain, 

"  The  state  of  the  pupils  varies  very  much  in  cases  of  pressure 
on  the  brain,  even  under  circurastanees  apparently  similar.  I 
have  seen  the  pupils  dilate  with  the  absence,  and  contract  with  the 
presence  of  light,  although  the  patient  lay  in  a  state  of  complete 
insensibility,  and  did  not  seem  to  be  at  all  conscious  of  the  impres- 
sions made  on  the  retina.  But  this  is  a  rare  occurrence,  and  for 
the  most  part  where  the  other  symptoms  of  pressure  are  present, 
the  pupils  are  insensible  and  motionless  ;  being  generally  dilated, 
but  sometimes  contracted.     It  is  not  uncommon  for  the  pupils  to 

*  See  his  valuable  paper  On  Injuries  of  the  Brain,  in  the  14th  volume  of  the 
Medico-Chirurgical  Transactions. 


660 

remain  for  a  time  in  a  state  of  dilatation,  then  to  become  suddenly 
contracted,  and  after  remaining  so  for  a  longer  or  shorter  time,  to 
become  again  dilated,  these  changes  taking  place  independently 
of  light  and  darkness.  I  have  observed,  especially  where  the  pu- 
pils have  been  dilated,  that  they  have  frequently  become  contracted 
immediately  after  the  abstraction  of  blood  ;  the  dilatation  return- 
ing as  soon  as  the  immediate  effect  of  the  blood-letting  on  the  cir- 
culation has  ceased.  Dr.  Hennen  mentions  a  case  in  which  blood 
was  extravasated  among  the  membranes  of  the  brain,  and  in  which 
the  pupils  were  observed  sometimes  to  become  dilated  with  an  in- 
crease, and  to  contract  with  a  diminution  of  light.  In  a  patient  in 
St.  George's  Hospital,  in  whom  there  was  an  extravasation  of 
blood  on  the  upper  part  of  the  right  hemisphere  of  the  cerebrum, 
and  no  cause  of  pressure  elsewhere,  both  pupils  were  insensible  and 
motionless  ;  but  the  right  pupil  was  in  a  state  of  dilatation,  and  the 
left  in  a  state  of  contraction.  In  another  patient,  in  whom  there 
was  fracture  and  depression  of  the  left  parietal  bone,  the  left  pupil 
was  permanently  dilated,  the  right  being  in  a  natural  state.  In  a 
third  case,  in  which  there  was  a  fracture  and  depression  of  the 
frontal  bone  above  the  right  supercihary  ridge,  there  was  a  dilata- 
tion of  the  pupil  of  the  left  eye  ;  and  again,  in  a  fourth  case,  where 
there  was  a  fracture  and  depression  in  the  same  situation  as  in  the 
case  last  mentioned,  and  no  cause  of  pressure  elsewhere,  both 
pupils  were  dilated  and  equally  insensible,  but  immediately  re- 
gained their  sensibility  and  power  of  contraction  on  the  depression 
being  elevated." 

Prognosis.  Among  those  who  recover  from  fractured  skull 
with  depression,  or  from  extravasation  of  blood  within  the  cranium 
in  consequence  of  an  injury  of  the  head,  there  are  some  in  whom 
the  symptoms  wholly  subside  in  the  course  of  a  few  days,  and 
others  in  whom  certain  remains  of  one  or  more  of  the  symptoms 
still  exist  after  the  lapse  of  many  years.  Such  variety  in  restora- 
tion is  remarkably  the  case  with  regard  to  the  sentient  power  of 
the  eye,  the  mobility  of  the  pupil,  and  the  activity  of  the  muscles 
supplied  by  the  third  pair  of  nerves. 

Treatment.  It  is  unnecessary  to  say  any  thing  here  on  the 
surgical  treatment  of  fractured  cranium  with  depression.  The 
medical  means  most  likely  to  assist  in  restoring  vision  in  such  cases, 
are  rest,  abstinence,  blood-letting,  laxatives,  and,  after  a  time,  an 
alterative  course  of  mercury.  Benefit  will  also  be  derived  from 
keeping  up  a  continued  discharge  from  the  neighbourhood  of  the 
bead. 

II.  Amaurosis  from  Cerebral  Plethora   and  Congestion. 

It  appears  to  be  universally  admitted,  not  only  that  amaurosis 
may  occasionally  result  from  a  sanguineous  overflow  to  the  brain, 
or  an  impeded  return  of  the  blood  from  that  organ,  but  that  one 
of  the  most  common  causes  of  this  disease  is  simple  turgescence  of 
the  vessels  supplying  the  internal  optic  apparatus. 


661 

Symptoms.  The  first  symptoms  with  which  the  plethoric  am- 
aurosis generally  shows  itself,  are  a  feeling  of  fulness  in  the  eye- 
balls, and  almost  uninterrupted  photopsia.  These  symptoms  are 
speedily  followed  by  stupifying  headach,  generally  accompanied  by 
vertigo,  and  tinnitus  aurium,  not  unfrequently  by  an  almost  total 
want  of  sleep,  and  keeping  pace  with  a  striking  diminution  in 
the  power  of  vision.  The  patient  is  commonly  of  an  athletic  habit, 
and  presents  signs  of  general  plethora.  In  some  instances,  however, 
the  reverse  of  this  is  the  case  ;  for  example,  in  pregnant  women, 
who  sometimes  have  been  known  to  suffer  tow«.rds  the  end  of  sev- 
eral successive  pregnancies  from  this  amaurosis.  Thesigns  of  local 
plethora  are  always  present.  The  eye  appears  fuller  than  natural ; 
it  seems  to  project  unusually  from  the  orbit ;  the  patient  moves  it 
liess  than  in  health ;  its  surface  is  suffused  with  red  vessels ;  the 
face  is  flushed,  and  the  temporal,  and  sometimes  even  the  carotid 
arteries  are  felt  strongly  throbbing.  The  pupil,  in  the  incipient 
stage,  may  not  be  much  affected,  being  neitlier  unnaturally  dilated 
nor  contracted,  and  still  varying  with  tolerable  liveliness  according 
to  the  degrees  of  light  to  which  the  eye  is  exposed- 

As  the  disease  advances  into  the  confirmed  stage,  the  headach 
becomes  irregular,  being  sometimes  severe,  at  other  times  scarcely 
felt.  The  patient  now  complains  principally  of  a  thick  gauze  or 
network,  which  renders  every  object  before  him  indistinct.  In 
clear  light,  this  network  seems  uniformly  obscure ;  but  in  the  dark, 
it  is  fiery  and  shining,  sometimes  appearing  reddish,  and  at  other- 
times  blueish.  This  symptom  is  increased  by  every  cause,  which 
increases,  even  for  an  instant,  the  local  plethora.  For  instance,  if 
the  patient  presses  violently  when  at  stool,  this  network  seems 
thicker  for  some  minutes  after  ;  and  if  this  cause  or  similar  causes 
of  increased  local  congestion  be  frequently  repeated,  and  the  exist- 
ing plethora  not  removed  by  proper  remedies,  vision  soon  becomes 
totally  extinguished.  This  indeed  almost  constantly  follows,  even 
when  there  are  no  such  occasional  augmentations  of  the  plethora, 
if  recourse  is  not  had  to  proper  treatment ;  but  not  so  rapidly  as 
when  such  occasional  causes  are  allowed  to  come  into  frequent  op- 
eration. At  last,  all  trace  of  sensibility  to  light  is  lost.  The  pa- 
tient continues  to  complain  of  stunning  headach.  He  complains 
also  of  a  feeling  as  if  tlie  eyelialls  weie  increasing  in  size :  and 
they  actually  feel  firmer  to  the  touch  than  natural.  The  pupil  be- 
comes fixed,  though  rarely  much  dilated.  The  patient  stares  on 
vacancy,  presenting  in  a  striking  manner  the  peculiar  look  of  the 
amaurotic. 

Exciting  causes.  Every  influence  capable  of  producing  or  in- 
creasing a  continued  or  frequently  repeated  plethora  of  the  head, 
may  be  regarded  as  an  exciting  cause  of  this  amaurosis.  Those 
who  are  of  a  plethoric  habit  are  generally  able  to  produce  a  slight 
degree  of  this  amaurosis  at  will.  When  they  stoop  forwards,  hang 
down  the  head,  tie  their  neckcloth  tight,  or  by  any  means  increase 


662 

the  circulation  of  blood  through  the  brain,  or,  perhaps,  to  speak 
more  correctly,  when  they  impede  in  any  way  the  return  of  that 
fluid  towards  the  heart,  they  excite  the  sensation  of  muscae  volitan- 
tes,  or  even  complete  temporary  blindness.  Boerhaave  relates  the 
case  of  a  man,  who  whenever  he  was  intoxicated,  laboured  under 
complete  amaurosis.  The  disease  came  on  by  degrees,  increasing 
with  the  quantity  of  wine ;  and  after  the  intoxication  went  off, 
his  vision  returned.*  Many  plethoric  persons  regularly  find  their 
vision  impaired  during  the  quickened  circulation  from  a  full  meal 
and  a  few  glasses  of  wine  ;  while  those  of  a  meagre  habit  not  un- 
frequently  find  their  vision  benefited  by  the  same  influences. 

The  following  influences  may  be  enumerated  as  likely  to  prove 
remote  causes  of  plethoric  amaurosis  ;  pregnancy,  tedious  and  diffi- 
cult parturition,  raising  and  carrying  heavy  loads,  long-continued 
occupations  which  strain  the  eyes  while  the  head  is  bent  forwards, 
employments  requiring  at  once  keen  exercise  of  sight  and  activity 
of  thought,  the  sudden  suppression  of  some  wonted  sanguineous 
discharge,  suppressed  menses,  the  neglect  of  periodic  blood-letting 
to  which  the  individual  has  been  accustomed  at  a  certain  period  of 
the  year,  violent  and  long-continued  vomiting,  a  forced  march  in 
hot  weather,  very  hot  baths  even  of  the  feet  only,  remaining  long 
in  an  over-crowded  assembly,  an  excessive  and  unaccustomed  de- 
bauch, frequent  constipation  of  the  bowels,  violent  pressing  while 
at  stool,  lying  with  the  head  uncommonly  low  during  the  night, 
large  scrofulous  or  other  swellings  in  the  neck  by  which  the  jugular 
veins  are  compressed,  impeded  reception  of  the  venous  blood  by  the 
heart  from  contraction  of  the  right  auriculo-ventricular  opening  or 
other  causes.  If  two  or  more  of  these,  or  similar  causes,  operate 
together,  and  more  especially  if  they  come  to  operate  suddenly  on 
an  individual,  perhaps  constitutionally  inclined  to  fulness  about  the 
head,  then  the  risk  of  plethoric  amaurosis  is  much  increased. 

Proximate  Cause.  Plethora  is  described  as  an  excessive  fulness 
of  vessels,  as  a  redundancy  of  blood,  as  redness  of  a  part  from  dis- 
tended blood-vessels,  as  redness,  heat,  and  tumour  even,  either  of 
the  whole  or  of  a  part  of  the  body,  from  the  same  cause ;  and  yet 
as  something  different  from  inflammation.  The  absence  of  acute 
pain  appears  one  of  the  chief  distinctions  of  plethora  from  inflam- 
mation ;  but  added  to  this  is  the  fact,  that  though  plethora  often 
ends  in  the  rupture  of  the  affected  vessels,  it  frequently  terminates 
without  any  such  event,  Avhile  inflammation,  though  it  is  some- 
times resolved,  is  in  general  attended  by  the  eff'usion  of  serum,  or 
of  coagulable  lymph,  the  formation  of  pus,  ulceration,  gangrene,  or 
even  by  several  of  these  events  in  succession. 

The  pathology  of  plethora  of  the  brain,  and  of  its  frequent  effect, 
apoplexy,  is  by  no  means  satisfactorily  understood  ;  for  while  many 
observations  would  lead  us  to  suppose  that  inflammation  of  the 

♦  De  Morbis  Oculorum,  p.  75.    Gottingse,  1746. 


663 

arterial  tunics,  and  deposition  of  calcareous  matter  between  their 
middle  and  innermost  layers,  were  intimately  connected  with 
these  diseases,  if  not  actually  their  proximate  causes,  leading  in 
apoplectic  cases  to  rupture  of  vessels  and  extravasation  of  blood,  the 
numerous  instances,  in  which,  after  death  from  apoplexy,  no  dis- 
eased appearances  whatever  could  be  detected  within  the  cranium, 
show  that  there  not  only  remains  room  for  farther  investigation 
upon  this  subject,  but  that  no  general  conclusion  can  at  present  be 
adopted  without  danger  of  faUing  into  some  serious  mistake. 

Prognosis.  So  long  as  plethoric  amaurosis  is  in  the  incipient 
stage,  and  the  power  of  vision  not  greatly  impaired,  the  practitioner 
may  venture  to  give  a  favourable  prognosis.  In  the  confirmed 
state,  or  when  the  power  of  vision  is  nearly  or  completely  extin- 
guished, the  prognosis  is  extremely  unfavourable.  Even  when 
the  disease  is  only  of  a  few  days'  standing,  if  no  power  of  vision 
be  present,  there  can  be  but  little  hope  of  its  recovery.  When  the 
patient  has  continued  for  several  months  in  this  state,  it  scarcely 
ever  happens  that  even  the  slightest  restoration  of  sight  is  effected. 
Treatment.  Slight  incipient  attacks  are  often  cured  by  rest, 
purgatives,  and  a  spare  diet.  In  more  threatening  cases,  general 
blood-letting  ought  to  be  practised  from  one  of  the  veins  of  the  arm, 
the  jugular  vein,  or  the  temporal  artery.  This  may  be  followed  up, 
if  it  seems  necessary,  by  local  blood-letting,  as  cupping  on  the  back 
of  the  neck,  cupping  on  the  temples,  or  the  application  of  leeches 
to  the  head.  Purgatives  are  particularly  useful  in  this  species  of 
amaurosis.  An  entire  abstinence  from  animal  food  must  be  ob- 
served, as  well  as  from  all  alcoholic  fluids.  Cold  applications  are 
to  be  made  to  the  head,  which  ought  previously  to  be  shaved. 
Complete  rest  of  the  eyes,  and  of  the  whole  body,  and  a  careful 
prevention  of  irritation  from  light,  must  be  enjoined. 

Depletion,  then,  and  the  antiphlogistic  treatment,  in  all  its  parts, 
are  the  means  upon  which  we  are  to  depend,  in  the  early  period 
of  this  amaurosis.  They  will  seldom  fail  us,  if  had  recourse  to 
within  the  first  two  or  three  days,  and  employed  with  the  neces- 
sary vigour. 

If  the  complaint  has  been  neglected  for  some  time,  or  treated 
without  depletion,  which  we  need  scarcely  distinguish  from  neglect, 
we  should  even  yet  have  recourse  to  blood-letting,  especially  if  the 
disease  has  not  continued  above  a  month  or  six  weeks.  If  deple- 
tion has  been  fully  tried,  but  without  benefit,  the  prospect  is  ex- 
tremely bad.  Excitation  of  the  absorbent  system  ought  now  to  be 
tried,  especially  by  means  of  mercury  and  counter-irritation.  The 
mouth  should  be  made  sore  by  a  course  of  calomel,  or  blue  pill ; 
the  head  blistered ;  and  an  issue  opened  by  caustic,  on  the  nape 
of  the  neck. 

Should  this  treatment  also  fail,  there  still  remain  many  other 
remedies  which  might  be  employed ;  but  in  plethoric  amaurosis, 
the  use  of  stimulants  must  be  pursued  with  more  than  ordinary 


6G4 

Gaution,  as  they  might  readily  produce  a  renewal  of  plethora,  or 
even  induce  apoplexy. 

III.  Amaurosis  from  Apoplexy. 

"When  cerebral  plethora  is  neglected,  it  is  exceedingly  apt  to  end 
in  that  sudden  abolition  of  the  powers  of  sense  and  motion,  to 
which  we  give  the  name  of  apoplexy.  Among  the  usual  symp- 
toms of  this  state,  we  find  loss  of  vision,  and,  most  frequently,  dila- 
ted pupils.* 

In  a  pathological  point  of  view,  apoplexy  resolves  itself  into  three 
varieties,  viz.  apoplexy  with  extravasation  of  blood,  apoplexy  with 
serous  effusion,  and  apoplexy  without  any  evident  morbid  appear- 
ance on  dissection.  The  last  mentioned.  Dr.  Abercrombie  calls 
simple  apoplexy.  Amaurosis  may  result  from  any  of  the  three, 
and  may  be  one  of  the  earliest,  or  one  of  the  latest,!  symptoms  to 
disappear. 

The  treatment  of  apoplectic  amaurosis  does  not  differ  in  an  es- 
sential particular  from  the  plan  above  recommended,  for  the  same 
disease,  arising  from  cerebral  congestion. 

IV.  Amaurosis  from  Aneurismal  Dilatation  of  the  Cerebral 

Arteries. 

It  was  a  conjecture  of  Mr.  Ware,  that  amaurosis  might  not  un- 
frequently  be  owing  to  dilatation  of  the  circulus  arteriosus. 
"  Should  then  the  dilatation,"  says  he,  "  take  place  in  the  posterior 
portion  of  the  circulus  arteriosus,  so  as  to  compress  the  nervi  rao- 
tores  oculorum,  the  consequence  will  be,  that  the  eyelids,  and  proba- 
bly the  e3^es  also,  wnll  lose  the  power  of  motion.  But  if  the  dilata- 
tion happens  in  the  anterior  portion  of  the  circulus^  as  the  compres- 
sion will  then  be  on  the  optic  nerves,  the  sight  must,  of  course,  be 
destroyed.  And  should  the  dilatation  take  place  in  both  portions, 
so  as  to  occasion  a  compression  both  on  the  optic  nerves  and  the 
nervi  motores  oculorum  at  the  same  time,  while  the  eyehds  w'ill 
hereby  be  rendered  immovable^  the  eyes  also  will  be  deprived  of 
sight  and  motion  together."  t 

Whether  this  is  actually  a  frequent  cause  of  amaurosis,  it  is  im- 
possible to  sa3^  Indeed,  the  want  of  accurate  dissections  is  one 
great  cause  of  the  obscurity  which  hangs  over  the  subject  of  amau- 
rotic diseases.  That  aneurism  of  the  cerebral  arteries  is  occasion- 
ally a  cause  of  amaurosis,  is  established  by  the  following  case,  rela- 
ted by  Mr.  Spurgin. 

Case.  T.  B.  by  occupation  a  labourer,  aged  57,  became  sud- 
denly insensible,  whilst  at  work,  about  the  beginning  of  March, 
but  quickly  recovered  without  assistance,  and  resumed  his  employ- 
ment. Three  weeks  after,  he  had  another  fit,  and  remained  in  a 
state  of  stupor  three  or  four  days.     He  complained  of  constant  pain 

*  See  page  576.  t  See  page  660. 

$  Observations  on  the  Cataract  and  Gutta  Serena,  p.  400.     Lond.  1812. 


665 

at  the  top  of  the  head,  much  increased  by  stooping,  and  which  fre- 
quently deprived  him  of  sleep.  His  countenance  appeared  dejected, 
heavy,  and  sallow.  He  was  extremely  morose  and  sullen,  often 
refusing  to  return  any  answer  to  questions,  and  frequently  fmding 
fault  with  his  attendants.  The  pupils  were  much  dilated,  but 
both  contracted  slowly  upon  the  approach  of  a  strong  light.  The 
right  eye  was  affected  with  cataract,  but  he  could  distinguish  hght 
from  darkness  with  this  eye.  His  pulse  was  generally  about  90, 
and  weak.  He  was  purged  freely,  and  a  blister  was  applied  to  the 
nape  of  the  neck.  These  remedies  somewhat  relieved  him  ;  but, 
after  a  few  days,  the  pain  became  as  constant  and  distressing  as 
ever.  He  had  now  eight  ounces  of  blood  taken  from  the  neck  by 
cupping,  which  greatly  mitigated  the  pain.  Four  days  after  this, 
while  sitting  at  dinner,  he  again  became  comatose  and  insensible ; 
his  respiration  hard  and  stertorous  ;  his  pulse  full  and  slow.  The 
pupil  of  the  right  eye  was  dilated ;  the  left  constricted  ;  both  im- 
movable. He  was  now  bled  freely  from  the  arm,  and  blistered  ; 
but  became  rapidly  worse,  and  died  next  morning. 

On  dissection,  it  was  found  that  the  dura  mater  adhered  more 
strongly  to  the  cranium  than  usual,  and  its  surface  presented  a 
blackish  blue  appearance  from  the  veins  beneath.  Adhesions  had 
formed  between  this  membrane  and  the  arachnoid,  and  between 
the  latter  and  the  pia  mater.  The  veins  of  the  pia  mater  were 
much  enlarged,  and  distended  with  blood.  Three  or  four  fungous 
patches  had  risen  from  the  surface  of  the  cerebrum,  through  the 
membranes,  and  had  adhered  to  the  bone.  Upon  raising  the  falx, 
it  was  found  to  have  united  to  both  hemispheres,  and  these,  below 
the  falx,  to  each  other.  A  considerable  quantity  of  deeply-tinged 
bloody  fluid  escaped  from  the  left  ventricle  as  soon  as  penetrated, 
and  a  small  coagulum  was  found  entangled  in  the  plexus  choroides. 
In  removing  the  upper  surface  of  the  right  hemisphere,  the  right 
lateral  venticle  was  cut  into,  being  raised  above  its  ordinary  level, 
and  a  quantity  of  coagulated  blood  was  discovered,  amounting  to 
three  or  four  ounces.  The  right  corpus  striatum  had  become  en- 
larged to  more  than  twice  its  natural  size.  The  surface  of  this 
body,  and  the  sides  of  the  ventricle,  were  abraded  and  pulpy,  leav- 
ing a  pinkish  green  appearance.  Removing  the  brain  from  the 
cranium,  a  long  red  streak  was  seen  upon  the  under  surface  of  the 
right  anterior  lobe,  and  under  this  an  abscess  was  discovered,  of 
rather  more  than  an  inch  in  length.  Immediately  behind  this, 
to  the  outer  side  of  the  olfactory  nerve,  and  before  the  junction 
of  the  optic  nerves,  an  aneurism,  of  the  size  of  a  hazel  nut,  of 
the  right  anterior  cerebral  artery,  was  found  pressing-  upon  the 
right  optic  nerve.  The  coats  of  the  aneurism  were  very  thick,  and 
its  cavity  contained  a  small  coagulum.  It  had  burst  on  its  upper 
surface  into  the  lateral  ventricle. 

The  sheath  of  the  right  optic  nerve,  particularly  at  the  entrance 
of  the  nerve  into  the  eye,  was  found  thickened  and  distended  with 


666 

blood,  and  adhered  firmly  to  the  proper  substance  of  the  nerve. 
The  veins  were  much  enlarged  on  the  back  of  the  sclerotic.  The 
choroid  had  its  usual  appearance  ;  but  the  retina  presented  a  pink- 
ish-grey colour,  and  the  ramifications  of  the  central  vein  could  be 
readily  seen  over  its  whole  surface,  as  far  as  the  lens.  The  pos- 
terior capsule  of  the  lens  was  opaque  ;  the  lens  semi-opaque,  and 
wasted  to  one-half  its  natural  size.* 

It  was  another  ingenious  conjecture  of  Ivir.  Ware,  that  dilatation 
of  the  central  artery  of  the  optic  nerve  might  sometimes  be  the 
cause  of  amaurosis.  He  had  often  suspected  that  this  might  be  the 
cause  of  the  disease,  in  those  instances  where  it  comes  on  suddenly, 
and  in  which,  though  all  objects  placed  directly  before  the  eyes 
are  totally  invisible,  there  remains  some  small  sense  of  light,  so  as 
to  give  a  confused  perception  of  objects  sidewise. 

This  conjecture  is  so  far  confirmed  by  a  pathological  preparation, 
in  the  possession  of  Professor  Schmidler,  of  Friburg,  viz.  an 
aneurism  of  the  central  artery  of  each  retina,  taken  from  a  prin- 
cess of  Baden,  who  was  for  a  long  time  blind,  and  to  whom  Plenck, 
Richter,  and  the  first  surgeons  of  Germany,  had  been  called.  She 
only  saw  a  little  on  looking  downwards.  The  aneurisms  com- 
pressed the  optic  nerves.f 

V.  Amaurosis  from  Inflammation,  brought  on  by  Exposure  of 
the  Eyes  to  Intense  Eighty  or  by  Over-exercise  of  the  Sight. 

This  is  one  of  the  most  frequent  varieties  of  amaurosis,  result- 
ing sometimes  from  a  single  short,  or  even  merely  momentary, 
exposure  to  very  vivid  Ught ;  in  other  cases,  from  long-continued, 
or  frequently  repeated,  examination  of  luminous  objects,  or  from 
intense  exercise  of  the  sight  even  upon  things  moderately  or  im- 
perfectly illuminated.  People,  for  example,  have  been  struck  blind 
from  viewing  an  eclipse  of  the  sun.  Long-continued  exposure  of 
the  eyes  to  the  hght  reflected  from  a  country  covered  with  snow, 
the  frequent  use  of  telescopes  or  microscopes,  reading  or  writing 
for  many  hours  together,  especially  by  candle-hght ;  these,  and 
such  Uke,  are  the  fruitful  causes  of  this  variety  of  amaurosis,  and 
are  more  apt  to  produce  their  injurious  effects  on  the  organs  of 
vision,  if  the  eyes  are  naturally  weak,  or  the  individual  inclined  to 
cerebral  congestion.  Literary  men,  engravers,  and  others,  whose 
occupation  is  at  once  sedentary,  and  requires  constant  exercise  of 
the  sight,  are  frequently  affected  with  this  amaurosis.  The  repose 
of  Sunday  has  a  remarkable  influence  on  the  subjects  of  this  dis- 
ease ;  tailors,  and  others,  observing,  that  at  no  period  of  the  week, 
do  they  see  so  well  as  on  Monday  morning. 

The  symptoms  are  variable,  but  chiefly  subjective. 

The  treatment  consists  principally  in  rest,  depletion,  mercury, 
and  counter-irritation. 

*  London  Medical  Repository  for  June,  1825,  page  443. 
+  Dictionaire  des  Sciences  Medicales,  Tom.  xxxv.  p.  20.    Paris,  1819. 


667 

Case.  1.  A  soldier,  unacquainted  with  the  proper  method  of  ob- 
serving an  eclipse  of  the  sun,  employed  for  that  purpose  a  piece  of 
opaque  glass,  with  a  transparent  point  in  its  centre.  Notwithstand- 
ing the  vivid  and  painful  impression  he  experienced  from  the  solar 
lays  which  passed  through  the  lucid  part  of  the  glass,  he  continued 
to  look  at  the  sun  till  the  end  of  the  eclipse.  He  was  soon  after- 
wards seized  with  vertigo,  and  pain  on  the  right  side  of  his  head, 
corresponding  to  the  eye  which  he  had  employed,  and  found  him- 
self almost  entirely  deprived  of  the  sight  of  that  eye.  Some  weeks 
afterwards,  finding  that  the  acute  pain  of  his  head  still  continued, 
he  came  under  the  care  of  Baron  Larrey,  who  observed  that 
the  vessels  of  the  eye  were  injected  with  blood,  the  pupil  a  little 
less  than  that  of  the  opposite  eye,  preserving,  however,  its  natural 
movements,  vision  very  obscure,  or  almost  lost.  After  two  blood-let- 
tings, one  from  the  temporal  artery,  and  the  other  from  the  jugu- 
lar vein,  Larrey  applied  blisters  to  the  temple,  and  to  the  nape  of 
the  neck.  Ice  was  then  employed  over  the  head,  followed  by 
nfbxas,  which  completely  re-estabhshed  the  patient's  sight ;  but  he 
still  retained  a  feehng  of  dull  pain  over  all  the  right  side  of  his 
head.* 

Case  2.  A  captain  in  the  navy  had  made  much  use  of  his  right 
eye,  for  many  years,  in  observations  with  telescopes  and  sextants. 
About  a  week  before  he  applied  to  Mr.  Travers,  he  observed  a 
mist  before  this  eye,  which  increased  until  it  was  so  dense,  that 
he  could  neither  distinguish  the  features  of  his  friends,  nor  the 
large  letters  of  a  title  page.  The  eye  was  free  from  inflammation, 
the  pupil  large  and  sluggish  ;  he  had  no  pain  either  in  the  eye 
or  the  head.  He  was  bled  copiously  from  the  arm  and  temple, 
and  briskly  purged  with  calomel  and  jalap,  at  short  intervals. 
Blisters  were  applied  to  the  temples.  He  then  rubbed  in  a  drachm 
of  the  strong  mercurial  ointment  for  several  nights  in  succession  ; 
this  produced  a  copious  flow  of  saliva  and  violent  diarrhoea,  so 
that  no  benefit  was  obtained.  By  a  calomel  and  opium  pill  taken 
night  and  morning,  his  gums  were  immediately  made  sore.  In 
three  days,  the  mist  began  to  clear,  and  he  was  delighted  to  find 
that  he  could  tell  the  hour  by  his  watch.  He  continued  improving 
so  rapidly,  that  at  the  expiration  of  ten  days,  he  could  read  an  or- 
dinary print  with  perfect  facility,  and  the  pupil  had  recovered  its 
ordinary  magnitude  and  activity.! 

Case  3.  The  same  author  has  recorded  the  case  of  a  young 
gentleman,  who  having  for  twelve  months  habituated  himself  to 
intense  study,  reading  and  writing  to  a  very  late  hour,  found  him- 
self affected  with  a  growing  imperfection  in  the  vision  of  his  left 
eye,  which  advanced,  unaccompanied  by  inflammation,  pain,  or 
any  external  symptom  of  disease.     It  seemed   at  first  a  film  be- 

*  Recueil  de  Memoires  de  Chirurgie,  p.  227.     Paris,  1821. 

t  Travers's  Synopsis  of  the  Diseases  of  the  Eye,  p.  166.     London,  1820. 


668 

fore  the  sight,  but  at  length  amounted  to  a  total  loss  of  sight.  The 
pupil  became  greatly  dilated,  and  had  little  or  no  action.  A  blister 
was  apphed  to  the  forehead,  which  drew  well,  and  was  kept  open 
for  ten  days,  the  eye  being  also  excluded  from  light  during  that 
period.  He  took,  at  the  same  time,  a  calomel  and  opiirni  pill 
thrice  a-day.  In  the  space  of  a  few  days,  his  mouth  became  sore ; 
the  pupil  acted,  though  unequally,  and  he  experienced  a  gradual 
recovery  of  vision.  In  the  course  of  six  weeks,  he  was  enabled 
to  resume  his  studies  and  could  perceive  no  defect  in  his  sight. 
He  had  gradually  reduced  the  dose  of  calomel,  and  now  discon- 
tinued it  for  the  decoction  of  sarsaparilla.  Four  months  afterwards, 
the  pupil  was  regular  and  active,  and  the  sight  unimpaired.* 

Case  4.  Mr,  Allan  mentions  the  case  of  a  master  of  a  printing 
office,  who  became  blind.  He  had  corrected  the  press,  and  was 
otherwise  engaged  in  reading,  for  eighteen  hours  out  of  the  twenty- 
four,  a  practice  which  he  continued  for  twelve  months,  notwith- 
standing an  evident  failure  of  his  sight.  At  the  end  of  this  time, 
the  amaurosis  was  so  complete,  that  he  could  not  distinguish  ooe 
object  from  another,  but  was  merely  capable  of  perceiving  the 
light,  so  as  to  find  his  way  in  the  streets.  He  continued  in  this 
state  for  several  years,  but  ultimately  recovered  sight.  The  treat- 
ment is  not  mentioned.! 

VI.  Amaurosis  from  Concussion,  or  other  Injury  of  the  Head- 

It  not  unfrequently  happens,  in  cases  of  concussion  of  the  brain, 
or  other  injury  of  the  head,  sufficient  to  stun  the  patient,  that  for 
a  time  he  remains  completely  insensible  to  external  impressions. 
This  state,  however,  does  not  usually  continue  long.  The  recove- 
ry, which,  in  general,  speedily  takes  place,  is  sometimes  complete ; 
while,  in  other  cases,  the  state  of  total  insensibility  is  followed  by 
one  in  which  the  sensibility  is  impaired,  but  not  destroyed.  The 
patient  is  not  affected  by  ordinary  impressions,  but  can  be  roused 
to  perception.  The  pupils,  in  this  stage,  contract  on  exposure  to 
hght,  and  are  sometimes  more  contracted  than  under  ordinary  cir- 
cumstances. These  symptoms  may  wholly  subside  in  the  course 
of  a  few  hours,  or  they  may  continue  for  three  or  four  days.  In 
the  latter  CEise,  it  frequently  occurs,  that  the  patient  regains  his 
sensibihty  for  a  time,  and  then  relapses  into  his  former  condition. 
Where  inflammation  of  the  brain  follows  concussion,  it  sometimes 
happens  that  there  is  no  interval  of  returning  sense,  the  symptoms 
of  concussion  being  gradually  converted  into  those  of  inflammation. 
But  it  is  also  often  the  case,  that  there  is  a  considerable  interval  of 
that  sort,  or  even  a  period  of  apparent  health,  before  the  symp- 
toms of  inflammation  show  themselves.  Even  years  may  elapse 
before  the  patient  becomes  aflfected  with  any  serious  indications  of 
cerebral  disease. 

*  Travers'a  Synopsis  of  the  Diseases  of  the  Eye,  p.  164.     London,  1820. 
t  Allan's  System  of  Svirgery,  Vol.  iii.  p.  187.     Edinburgh,  1824. 


669 

The  inflammation  which  succeeds  to  concussion,  and  other  inju- 
ries of  the  head,  may  be  more  or  less  extensive,  and  more  or  less 
acute ;  affecting  tlie  whole  contents  of  the  cranium,  and  rapidly 
proving  fatal,  or  limited  to  some  particular  part  of  the  brain,  and 
inducing  dea^h  only  after  a  series  of  the  most  distressing  symptoms, 
as  violent  headach,  amaurosis,  palsy,  convulsions,  and  the  like. 
These  symptoms  occur  sometimes  in  one  order,  and  sometimes  in 
another.  Our  knowledge  of  diseases  of  the  brain  is  not  yet  suffi- 
ciently exact,  to  enable  us  to  refer  the  symptoms  which  occur,  to 
the  particular  seats  or  terminations  of  the  in:flammatory  action. 

The  appearances  on  dissection  consist  in  increased  vascularity, 
ramollissement,  diffuse  or  encysted  abscess,  induration^  &c. 

Case  1.  A  young  gentleman,  at  12  years  of  age,  received  a  rap 
at  school  with  the  edge  of  a  flat  ruler,  because  he  was  dull  at  his 
learning.  The  blow  was  on  the  right  side  of  th«  head,  and  a  small 
wound  was  the  consequence;  which,  for  the  space  of  six  years, 
nothing  would  heal.  It  then  healed,  and  he  very  soon  afterwards 
perceived  that  his  sight  was  beginning  to  fail.  In  this  respect  he 
continued  to  decline,  till,  at  length,  he  became  quite  blind.  Added 
to  this,  he  now  began  to  suffer  from  epileptic  fits,  which  most  fre- 
quently returned  upon  him  every  day. 

The  only  thing  considered  likely  to  afford  any  prospect  of  real 
advantage,  was  the  removal  of  a  portion  of  bone  by  the  trephine. 
There  was  no  particular  appearance  in  the  cicatrice  of  the  old 
wound,  where  the  blow  had  been  received  ;  nor,  on  exposing  the 
bone,  was  it  fovmd  diseased,  or  even  discoloured.  On  removing 
the  piece  separated  by  the  crown  of  the  trephine,  some  blood  and 
serous  fluid  escaped  from  between  the  skull  and  dura  mater.  This 
membrane,  however,  did  not  appear  to  have  lost  its  healthy  colour. 
By  the  nex/t  day,  the  pupil  of  each  eye  had  recovered  its  natural 
sensibihty,  dilating  and  contracting,  according  to  the  degree  of 
light.  The  blindness  remained  absolute,  as  before  the  operation. 
The  patient's  strength  hourly  declined ;  a  degree  of  low  fever  su- 
pervened ;  and  on  the  third  day  after  the  application  of  the  tre- 
phine, he  was  seized  with  an  unusually  severe  fit,  soon  after  which 
he  expired. 

On  opening  the  head,  the  cranium  was  to  appearance  every 
where  healthy,  and  so  was  the  dura  mater.  Below  the  part  where 
the  dura  mater  had  been  exposed  by  the  trephine,  and  consequently 
opposite  the  seat  of  the  original  wound,  the  pia  mater  had  evidently 
suffered  from  chronic  inflammation,  but  this  appearance  was  cir- 
cumscribed. On  cutting  into  the  brain,  it  was  found  indurated  to 
a  considerable  degree,  and  this  induration  had  extended  itself  to 
the  whole  of  the  middle  lobe  of  the  cerebrum,  commencing  upon 
the  surface  of  the  hemisphere,  and  passing  through  the  brain  down 
to  the  basis  of  the  cranium.* 

*  Practical  Observations  in  Surgery  and  Morbid  Anatomy.  By  John  Howship ; 
p.  131.     London,  1816. 


670 

Case  2.  A  young  lady,  when  about  15  years  of  age,  received  at 
play  a  slight  tap,  rather  than  a  blow,  on  the  right  side  of  her  head. 
It  gave  her  at  the  moment  rather  severe  pain  ;  but  she  disregarded 
it;  and  no  immediate  consequences  of  any  kind  followed  more 
than  a  common  headach,  commencing  always  in  the  part  which 
had  been  struck.  For  above  thirty  years  she  continued  subject  to 
these  attacks,  and  then,  though  naturally  very  lively,  began  to 
grow  heavy,  and  sometimes  stupid  and  sleepy,  without  any  known 
additional  cause.  This  disposition  continued  gradually  to  increase, 
till,  for  the  last  year  and  a  half  of  her  life,  it  was  very  dijfficult  to 
keep  her  awake ;  but  when  she  was  awake,  though  it  was  but  for 
half  an  hour,  she  displayed  all  her  natural  brilliancy  of  conversa- 
tion. Then,  all  at  once,  she  would  drop  asleep  again,  not  to  be 
roused.  In  this  way  she  went  on  till  a  perpetual  comatose  state 
took  place,  and  she  died  convulsed.  Her  vision  had  become  very 
much,  although  very  gradually,  impaired. 

On  dissection,  as  soon  as  the  scalp  was  removed  from  over  the 
right  parietal  bone,  a  portion  of  the  bone,  about  the  size  of  a  crown 
piece,  directly  under  the  part  where  the  blow  had  been  received, 
and  to  which  she  had  invariably  pointed  as  the  seat  of  her  pain, 
was  observed  to  be  of  a  very  dark  colour.  On  removing  the  right 
parietal  bone,  the  part  of  it  which  appeared  discoloured,  was  found 
to  be  transparent,  and  almost  wholly  absorbed.  It  had  acquired 
the  dark  colour,  which  it  at  first  presented,  from  the  portion  of  the 
right  hemisphere  of  the  brain,  directly  under  it,  being  perfectly 
black,  and  the  colour  appearing  through  the  bone,  for  the  dura 
mater  at  this  part  was  altogether  removed  by  absorption.  Had 
she  lived  much  longer,  the  bone  also  would  have  been  quite  ab- 
sorbed, and  the  brain  itself  would,  in  all  probability,  have  protruded. 
The  portion  of  brain  under  the  seat  of  the  injury  was  indurated 
and  scirrhous,  and  this  change  had  taken  place  through  the  whole 
of  the  middle  lobe  of  the  cerebrum.  The  colour  was  dark  livid. 
Every  other  part  of  the  brain  was  perfectly  sound,  nor  was  there 
any  disease  in  the  thorax  or  abdomen.  The  disease  above  de- 
sciibed,  had  so  pressed  on  the  optic  nerves  at  their  origin,  as  to 
have  made  them  as  flat  as  a  piece  of  tape,  thereby  occasioning  the 
loss  of  sight,  which,  for  some  time  before  death,  had  amounted  to 
almost  total  darkness.* 

YII.  Amaurosis  from  Inflammation  of  the  Brain,  consequent 
to  Scarlatina. 

I  have  selected  this  as  one  of  the  most  remarkable  of  the  hydro- 
cephalic amauroses. 

It  is  no  uncommon  thing  for  a  child,  recovering  from  scarlatina, 
to  be  seized,  perhaps  after  some  exposure  to  cold,  with  headach, 
which,  after  a  short  time,  is  followed  by  convulsions,  and  these  by 

*  Practical  Observations  in  Surgery  and  Morbid  Anatomy.  By  John  Howship ; 
p.  119.    London,  1816, 


671 

blindness  and  coma.  These  symptoms  may  have  been  preceded 
by  the  oedema  which  frequently  supervenes  upon  scarlatina,  and, 
on  thai  account,  are  apt  to  be  ascribed  to  sudden  effusion  in  the 
brain  ;  but  the  opinion  of  Dr.  Abercrombie  is,  I  think,  undoubt- 
edly correct,  that  the  disease  is  inflammatory,  and  that  the  patient 
can  be  saved  only  by  the  most  vigorous  antiphlogistic  treatment — 
blood-letting,  purgatives,  and  the  Hke.  Upon  this  plan,  many  cases 
perfectly  recover ;  some  remain  ever  afterguards  liable  to  epilepsy  ; 
others  die,  and  present  the  usual  appearances  of  inflammatory  af- 
fections of  the  brain. 

Case  1.  A  girl,  8  years  old,  on  the  morning  of  the  third  day 
of  the  dropsical  disease,  consequent  to  scarlatina,  complained  of 
headach,  which  in  the  course  of  the  same  day  became  extremely 
violent.  In  the  evening  she  was  seized  with  convulsions,  which, 
according  to  the  report  of  her  mother,  continued  nineteen  hours, 
with  scarcely  any  intermission.  They  then  ceased,  but  returned  in 
two  hours.  In  this  interval  it  was  discovered  that  she  was  blind, 
and  that  her  pupils  were  much  dilated.  The  convulsions,  after 
they  returned,  continued  thirty-six  hours  ;  and  the  patient  remained 
bhnd:  eight  hours  after  they  left  her.  This  child  recovered.  Her 
swellings,  which  were  confined  to  the  face  and  hands,  disappeared 
while  the  convulsions  were  present,  but  returned  after  they  had 
ceased.* 

Case  2.  A  boy,  13  years  of  age,  on  the  morning  of  the  seventh 
day,  after  his  face  had  begun  to  swell,  was  seized  with  headach  ; 
in  the  evening  his  limbs  were  convulsed,  and  his  sight  was  almost 
entirely  lost.  His  memory,  however,  and  the  faculties  of  his  mind, 
seemed  unimpaired.  His  convulsions  ceased  after  half  an  hour ; 
but  they  returned  in  an  hour,  and  lasted  again  about  half  an  hour. 
In  this  way  he  was  alternately  attacked,  and  relieved,  eleven 
times  in  twenty  hours.  During  the  convulsions,  the  external  swell- 
ings left  him,  and  he  complained  much  of  a  pain  in  his  belly,  in- 
creased by  pressure.  When  the  convulsions  had  ceased  altogether, 
his  sight  became  less  imperfect ;  but  his  countenance  was  pale,  and 
his  pulse  feeble  and  very  frequent.  The  following  morning  he 
died.t 

VIII.  Amaurosis  from  Inflammation  of  the  Brain,  consequent 
to  suppressioti  of  the  Menses. 

When  amaurosis  occurs  as  a  disease  of  conversion,  or  as  a  con- 
sequence of  the  suppression  of  any  wonted  evacuation,  it  is  often 
difficult  to  say,  whether  the  disease  of  the  brain,  to  which  the  af- 
fection of  the  optic  apparatus  is  to  be  attributed,  is  congestive,  inflam- 
matory, or  hydrocephalic.     In  a  practical  point  of  view,  this  diffi- 

*  Observations  on  the  Dropsy,  which  succeeds  Scarlet  Fever.  By  William 
Charles  Wells,  M.  D.,  in  the  Transactions  of  a  Society  for  the  Improvement  of  Medi- 
cal and  Chirurgical  Knowledge.     Vol.  Hi.  p.  177.     London,  1812. 

t  Ibid.    Vol.  iii.  p.  178.    London,  1812. 


672 

ciilty  is  not  very  important,  as  the  relief  of  the  brain  by  bloodletting 
and  purging,  and  the  recall  of  the  suppressed  evacuation,  or  origi- 
nal disease,  would  still  remain  the  chief  indications,  whatever  was 
the  nature  of  the  cerebral  affection. 

Case  1.  The  following  case  is  related  by  Mr,  Brown,  of  Mussel- 
burgh. The  patient  was  a  female  about  40  years  of  age.  Upon 
walking  a  considerable  distance,  in  very  warm  weather,  the  cata* 
menia  appeared,  nearly  upon  the  termination  of  her  walk,  and 
being  very  much  heated,  she  drank  a  full  draught  of  cold  skim- 
milk,  which  almost  instantly  brought  on  oppression  about  the 
praecordiaj  headach,  and  a  total  cessation  of  the  menstrual  discharge. 
In  a  few  hours  more,  the  headach  became  excruciating,  and  symp- 
toms of  hemiplegia  presented  themselves,  with  an  attack  of  amau- 
rosis in  the  left  eye. 

By  means  of  copious  local  and  general  bleeding,  bhsters,  and 
purging,  considerable  relief  was  obtained  ;  but  the  affection  of  the 
eye  remained  the  same.  When  the  period  of  menstruation  re- 
turned, no  discharge  occurred.  Being  of  opinion  that  no  complete 
cure  could  be  effected,  unless  the  recurrence  of  the  catamenia  could 
be  obtained,  Mr,  Brown  directed  his  attention  chiefly  to  this  object. 
At  the  end  of  six  months  they  re-appeared,  which  was  followed 
soon  after  by  the  complete  restoration  of  sight.* 

Case  2.  A  lady,  aged  30,  about  the  5th  of  June,  1824,  was  ex- 
posed to  cold  and  fatigue  during  the  flow  of  the  menses,  which 
ceased  prematurely.  After  this,  she  was  for  some  days  observed 
to  be  remarkably  languid,  dull,  and  depressed.  The  pulse  was 
natural ;  she  complained  of  slight  headach  ;  but  her  appearance 
had  excited  an  apprehension  rather  of  aberration  of  mind  than  of 
any  bodily  complaint ;  and  in  this  manner  the  affection  went  on 
for  nine  or  ten  days.  Dr.  Abercrombie  saw  her  on  the  15th  ;  she 
was  then  odd  in  her  manner,  abrupt  and  absent,  but  quite  sensi- 
ble when  spoken  to ;  complained  of  slight  headach  ;  pulse  a  little 
frequent.  On  the  16th,  she  was  much  oppressed  ;  and  on  the 
17th,  in  a  state  of  nearly  perfect  coma,  which  continued  on  the 
18th.  On  the  19th,  after  free  purging  with  croton  oil,  she  came 
out  of  the  coma  entirely,  was  quite  sensible  to  every  thing,  and  no 
alarming  symptom  remained,  except  that  she  sometimes  saw  ob- 
jects remarkably  distorted,  and  sometimes  double.  At  other  times 
her  vision  was  quite  natural;  the  pulse  was  frequent,  and  the 
tongue  loaded.  In  this  state  she  continued  for  several  days  ;  she 
then  complained  again  of  headach  ;  there  was  occasional  incohe- 
rence; the  sight  was  more  indistinct,  with  dilated  pupil;  and  the 
pulse  increased  in  frequency.  The  pulse  continued  to  rise,  with 
much  incoherent  talking,  and  sinking  of  strength  ;  and  she  died 
on  the  20th,  without  coma. 

The  ventricles  were  distended  with  fluid,  and  there  was  exten- 

*  Edinburgh  Medical  and  Surgical  Journal,  Vol.  xxvi.  p.  279.     Edinburgh,  1826, 


673 

sive  ramollissement  of  the  septum  and  fornix.     There  was  no  other 
morbid  appearance.* 

IX.  Amaurosis  from  inflammation  of  the  Brain,  consequent  to 

Suppressed  Purulent  Discharge. 

Case.  A  wagoner,  aged  45  years,  undertook  a  journey  in  wet 
and  cold  weather.  The  discharge  from  ulcers  of  his  legs,  which 
had  for  many  years  continued  open,  was  suppressed,  and  he  became 
blind.  Fourteen  days  after,  he  was  brought  to  the  hospital.  He 
saw  nothing,  not  even  a  brightly  lighted  window.  The  pupil  was 
oblong  and  extremely  dilated.  Beer  immediately  pronounced  the 
most  favourable  prognosis,  especially  as  there  were  present  internal 
sensations  of  light  in  the  eye,  without  varicosity,  and  without  change 
in  the  humours.  He  had  cured  more  than  twenty  such  amaurotic 
patients,  by  restoring  the  purulent  discharge.  The  prescriptions 
were  sinapisms,  of  the  size  of  the  hand,  to  the  ulcers  of  both  legs, 
pediluvia  with  mustard,  and  internally  three  of  the  following  pow- 
ders daily — R  Sulphuris  aurati  Aritimonii  gr.  i.  Camphorm 
gr.  ii.  Plorum  Sulphuris  gr.  vi.  Sacchari  gr.  x.  Misce.  The 
sinapisms  were  renewed  daily,  and  on  the  tenth  day  vision  began 
to  return.  The  sinapisms  acted  severely  on  the  ulcers,  which  be- 
came deep  cavities,  with  dark-coloured  edges.  In  thirty  days,  vi- 
sion was  almost  completely  restored.! 

X.  Amaurosis  from,  l7iflam,m,ation  of  the  Brain,  consequent  to 

/Suppressed  Ferspiration.l 

Cases  are  related  by  various  authors,  in  which  amaurosis  appeared 
to  arise  from  exposure  to  cold,  or  sudden  suppression  of  perspiration. 
Thus,  Arrachart  mentions  the  case  of  a  young  woman,  who,  dur- 
ing the  excessive  heat  of  summer,  having  carried  a  load  of  clothes 
to  the  river,  and  arriving  in  a  state  of  profuse  perspiration,  plunged 
her  hands  into  the  water.  The  cold  seized  her,  her  skin  became 
instantly  dry,  and  in  less  than  a  quarter  of  an  hour  she  was  de- 
prived of  sight.  He  relates,  also,  the  case  of  a  very  corpulent  young 
man,  who  having  remained  for  a  long  time  in  a  room,  strongly 
heated  by  a  stove,  had  the  imprudence  to  go  out  while  completely 
perspiring.  The  cold  air  suddenly  suppressed  the  perspiration. 
He  went  to  bed  with  violent  headach,  and  next  morning  awoke 
blind.  In  both  cases,  the  pupils  remained  black,  dilated,  and  im- 
movable, the  eyes  fixed  and  stupid,  and  the  body  oppressed  and 
actionless.§ 

Besides  fixed  pupil  we  generally  observe  that  in  this  amaurosis 
the  motions  of  the  eyeball  are  impeded,  especially  in  one  particular 

*  Pathological  and  Practical  Researches  on  Diseases  of  the  Brain,  p.  143.  Edin- 
burgh, 1829. 

t  Osiander's  Nachrichten  von  Wien,  p.  76.     Tubingen,  1817. 

t  Rheumatic  Amaurosis  of  Beer.    Neuralgic  Amaurosis  of  Belcher. 

§  Memoires  de  Chirurgie,  par  J.  N.    Arrachart ;  p.  901-    Paris,  1805- 

85 


674 

direction,  while  in  some  instances,  a  complete  luscitas  is  present. 
Almost  always  we  find  accompanying  this  disease  a  considerable 
loss  of  power  in  the  levator  palpebree  superioris,  and  not  uncom- 
monly a  complete  palsy  of  that  muscle.  Indeed  the  paralytic  state 
of  the  upper  eyelid,  and  the  inabihty  to  move  the  eyeball  freely 
from  side  to  side,  are  the  symptoms  which  at  first  view  strike  the 
observer  as  the  most  remarkable.  Double  vision,  when  both  eyes 
are  exposed,  and  excessive  vertigo,  are  symptoms  evidently  depend- 
ing on  want  of  the  natural  consentaneous  movements  of  the  eyes. 

There  is  always  more  or  less  intolerance  of  light  with  epiphora, 
so  that  instead  of  the  patient  seeking  constantly  for  more  light,  as 
in  some  varieties  of  amaurosis,  we  probably  find  him  in  a  darkened 
room,  with  his  eyes  shaded.  There  accompanies  this  disease  such 
an  aching  pain  in  the  eye,  as  is  usually  described  under  the  name 
of  neuralgia,  extending  to  the  whole  orbital  region,  or  over  the  side 
of  the  head  ;  in  some  cases  slight,  in  others  severe.  Occasionally 
we  find  rheumatism  of  the  extremities  attending  this  amaurosis ; 
in  other  cases,  all  rheumatic  affection  has  ceased,  except  in  the  eye 
and  its  immediate  neighbourhood,  and  we  may  even  meet  with 
patients  who  have  scarcely  suffered  at  all  from  rheumatic  pain, 
either  in  the  eye,  or  in  any  other  part  of  the  body.  This  species 
of  amaurosis  rarely  goes  the  length  of  complete  blindness. 

Causes.  This  disease  appears  frequently  to  arise  from  continued 
exposure  of  the  head  to  cold,  particularly  in  those  individuals  who 
perspire  much  and  easily  on  the  head,  and  especially  on  the  fore- 
head. In  other  cases,  as  in  that  of  the  young  man  already  quoted 
from  Arrachart,  the  suppression  of  perspiration  is  more  general,  or 
takes  place,  as  in  the  case  of  the  young  woman  related  by  the 
same  author,  in  consequence  of  the  application  of  cold  to  the  ex- 
tremities. 

Diagnosis.  The  suddenness  of  the  attack,  and  obviousness  of 
the  exciting  cause,  will  in  general  serve  for  the  ready  discrimi- 
nation of  this  amaurosis,  from  insensibility  of  the  retina,  with  palsy 
of  the  muscles  supplied  by  the  third  pair,  arising  from  the  pressure 
of  some  morbid  formation  within  the  cranium. 

Prognosis.  Under  certain  circumstances,  the  prognosis  is  by  no 
means  unfavourable.  Beer  mentions,  that  he  had  succeeded  in 
curing  the  greater  number  of  such  cases  completely,  when  taken 
in  time. 

Treatment.  The  general  treatment  consists  in  depletion  by 
blood-letting  and  purging,  followed  by  the  use  of  diaphoretics  and 
alteratives.  Calomel  with  opium,  Dover's  powder,  guaiac,  cam- 
phor, and  sarsaparilla,  prove  essentially  serviceable ;  to  which  may 
be  added,  chalybeate  and  arsenical  preparations. 

Amongst  external  applications,  vesicatories  hold  the  chief  place. 
They  are  to  be  applied  alternately  behind  the  ear,  on  the  temple 
and  on  the  forehead,  so  that  a  continued  succession  of  thera  may 
be  kept  up.     If  the  rheumatic  pain  has  left  the  region  of  the  eye- 


675 

brow,  and  concentrated  itself  in  the  eyeball,  friction  round  the  orbit, 
with  a  stimulating  liniment,  containing  opium  or  hyosciamus,  may 
be  used  with  advantage.  If,  for  a  considerable  time,  there  has  not 
been  the  shghtest  trace  of  rheumatic  pain  in  the  eyeball,  orbit,  or 
head,  but  the  power  of  vision  is  still  defective,  and  the  upper  eye- 
lid, or  one  or  other  of  the  muscles  of  the  eyeball  paralytic,  electricity 
or  galvanism  may  be  tried.  A  caustic  issue,  in  the  hollow  between 
the  lower  jaw  and  the  mastoid  process,  frequently  effected  a  com- 
plete cure,  in  the  hands  of  Beer,  when  all  other  means  had  failed. 
The  issue  ought  to  be  continued  for  some  weeks  after  the  symp- 
toms have  yielded. 

Case  1.  Mrs.  B.,  about  35  years  of  age,  applied  to  Mr.  Ware 
on  account  of  an  inability  to  raise  the  left  upper  eyelid,  which  came 
first  on  after  a  severe  fit  of  rheumatism.  There  was  no  appear- 
ance of  inflammation,  nor  was  the  pupil  dilated  ;  but  the  sight  was 
dim,  and  occasionally  the  patient  experienced  considerable  pain  in 
the  eye,  extending  also  to  the  whole  side  of  the  head.  She  was  a 
thin  woman,  her  pulse  weak,  and  her  general  look  conveying  the 
idea  of  debility. 

The  electric  aura,  with  small  sparks,  had  been  applied  to  her 
eye  for  five  or  six  minutes  daily,  for  some  weeks ;  the  eyelids  had 
been  embrocated  with  camphorated  spirits  ;  and  chalybeate  draughts 
had  been  given  internally;  but  these  remedies  had  not  afforded 
any  relief  The  patient  had  been  married  several  years,  but  had 
never  been  pregnant ;  and  Mr.  Ware  was  informed  by  her  apothe- 
cary, that  shortly  after  her  marriage,  she  had  an  eruption  on  her 
skin  of  a  very  doubtful  nature,  on  account  of  which  she  had  under- 
gone a  regular  course  of  mercury,  which  had  completely  removed 
it.  In  consequence  of  this  information,  notwithstanding  that  at 
the  time  Mr.  W.  was  consulted  there  were  no  appearances  of  a 
syphilitic  nature,  he  thought  it  not  improbable  that  some  change 
might  have  been  wrought  on  the  constitution,  either  by  the  disease 
above  mentioned,  or  by  the  remedies  administered  for  its  cure, 
which  contributed  to  produce  the  present  disorder.  With  a  par- 
ticular view  to  this  circumstance,  he  advised  her  to  take  half  a 
drachm  of  the  powder  of  sarsaparilla  twice  in  the  day,  and  to  drink 
after  it  each  time,  half  a  pint  of  the  decoction  of  sarsaparilla.  He 
apphed  a  slip  of  sticking  plaster  to  the  eyelid,  and  continued  it  lon- 
gitudinally over  the  forehead,  in  such  a  way  that  it  might  give  the 
lid  a  gentle  support;  and  being  informed  by  the  patient,  that  a 
rheumatic  pain  in  her  neck  had  been  relieved  by  the  use  of  elec- 
tricity, he  advised  it  to  be  continued  in  the  form  of  aura,  but  not 
of  sparks. 

At  the  end  of  a  week,  when  she  had  not  acquired  any  additional 
power  to  raise  the  Ud,  and  her  pulse  was  increased  in  strength,  Mr. 
W.  was  induced  to  open  the  vein  which  passes  by  the  side  of  the 
nose,  and  took  from  it  six  ounces  of  blood.  A  gentle  purgative  was 
given,  and  she  was  directed  to  continue  the  sarsaparilla.     On  a 


676 

farther  trial  of  electricity,  it  became  evident  that  it  was  not  suited 
to  the  present  state  of  the  patient,  since,  after  its  application,  the 
uneasiness  of  the  eye  was  each  time  increased,  and  the  pain  some- 
times continued  a  great  part  of  the  day.  She  was,  on  the  contrary, 
so  decidedly  relieved  by  the  evacuations  above  mentioned,  both  in 
respect  of  ease  and  of  power  to  raise  the  lid,  that  two  days  after- 
wards, Mr.  W.  directed  three  leeches  to  be  applied  on  the  left  tem- 
ple. These  afforded  still  farther  assistance.  They  were  reap- 
plied after  three  days  more ;  and  the  amendment  they  afforded 
being  again  evident,  they  were  repeated  every  three  or  four 
days  for  a  fortnight ;  after  which,  without  any  farther  change 
in  the  treatment,  the  hd  recovered  its  full  power,  the  sight  be- 
came clear,  and  the  eye  and  head  were  perfectly  freed  from  pain.* 

Case  2.  Joseph  Moxly,  aged  32,  of  the  phlegmatic  tempera- 
ment, applied  to  Dr.  Belcher,  July  15th,  1825,  complaining  of  total 
loss  of  vision  of  the  left  eye.  At  the  same  time,  he  was  suffering 
exceedingly  from  acute  pain  of  the  temple,  eyeball,  ear,  cheek,  side 
of  the  head,  and  upper  part  of  the  neck  of  the  same  side.  The  in- 
teguments of  the  face  and  scalp  of  that  side  were  tender,  and  the 
paroxysm  was  aggi'avated  and  brought  on  by  the  shghtest  pressure, 
attempt  at  mastication,  noise,  or  even  by  a  current  of  air.  He  had 
a  remission  every  morning  and  noon,  and  a  severe  exacerbation 
towards  evening.  The  pupil  of  the  amaurotic  eye  was  dilated  and 
immovable,  and  the  upper  eyelid  paralyzed.  He  had  been  a  fort- 
night deprived  of  vision,  and  for  twelve  days  before  that,  had  con- 
tinued to  suffer  fi-ora  the  neuralgic  affection.  The  tongue  was 
furred,  he  had  a  bitter  taste  in  the  mouth,  with  costiveness,  and 
tenderness  in  the  epigastrium  ;  pulse  slow ;  aspect  languid  and 
pale;  very  despondent  at  the  idea  of  being  blind  so  early  in  life. 

The  obvious  primary  indication  being  to  correct  the  derangement 
of  the  primae  viae,  5  grains  of  blue  pill,  with  5  of  extract  of  colo- 
cynth,  in  Iwo  pills,  were  ordered  at  bedtime,  to  be  followed  by  a 
saline  purge  in  the  morning.  As  it  appeared  probable  that  a  stim- 
ulating vapour,  directed  to  the  eye,  would  assist  in  restoring  the  par- 
alyzed retina  and  eyelid,  the  liquor  ammoniee  puree  was  ordered, 
until  lachrymation  and  conjunctival  redness  should  follow.  These 
measures  being  continued  for  three  days,  the  symptoms  of  digestive 
derangement  were  reheved,  but  the  loss  of  vision  and  the  neuralgia 
remained  unabated.  Dr.  Belcher  now  resolved  to  give  a  trial  to  the 
carbonate  of  iron.  The  patient  was  ordered  to  take  half  a  drachm 
three  times  a  day,  and  to  go  on  with  his  evening  pills,  morning 
purge,  and  amraoniacal  vapour.  No  change  took  place  for  four 
days,  when  the  neuralgic  paroxysms  became  less  severe,  and  the 
upper  lid  was  observed  to  move,  though  the  amaurotic  state  of  the 
eye  was  unaltered.  Next  morning,  on  awaking  from  sleep,  to  his 
inexpressible  satisfaction,  the  patient  found  that  he  could  discern 

*  Observations  on  the  Cataract  and  Gutta  Serena,  p.  424.    Lond.  1812. 


677 

daylight,  and  move  his  eyelids  freely.  The  neuralgia  had  also 
nearly  disappeared.  On  the  sixth  day  from  commencing  the  car- 
bonate of  iron,  and  after  18  doses,  the  neuralgia  had  disappeared, 
the  pupil  contracted,  the  lid  moved  freely,  and  vision,  though  still 
indistinct,  was  improving.  The  treatment  was  regularly  continued, 
with  daily  improvement.  By  the  15th  of  August,  vision  was 
completely  restored  ;  the  head  was  free  from  pai<a ;  and  the  diges- 
tive organs  were  in  better  order  than  they  had  been  for  a  loHg 
time.* 

Case  3.  J.  Powell,  a  very  healthy  old  man,  77  years  of  age,  had 
been  for  many  years  subject  to  an  excessive  /perspiration  from  the 
feet,  more  especially  upon  taking  any  exercise.  This  tendence 
had  for  several  years  been  so  great  an  inconvenience,  as  to  oblige 
him  sometimes  to  change  his  stockings  several  times  in  die  coursy 
of  the  day.  He  was  one  day  advised  by  a  neighbour  to  apply  the 
fresh  leaves  of  dock  to  his  feet,  and  was  assured  that  this  would  ef- 
fectually cure  his  complaint.  Accordingly  he  laid  a  single  dock 
leaf  to  the  sole  of  each  foot,  and  very  soon  perceived  that  they  had 
taken  effect.  He  felt  a  sensation  of  tingling  and  irritation,  where- 
ever  the  leaves  came  in  contact  with  the  skin.  Within  half  an 
hour  after  they  were  applied,  he  experienced  great  uneasiness  and 
pain  in  the  head.  This  pain  soon  became  very  distressing,  partic- 
ularly over  the  eyes,  which  it  is  remarkable  were  so  quickly  affected, 
that  before  the  leaves  had  been  applied  an  hour,  he  was  nearly  to- 
tally blind. 

On  being  admitted  into  St.  George's  Infirmary,  it  appeared  that 
he  could  perceive  a  strong  light,  and  could  make  out  the  figure  of 
an  opaque  object,  placed  between  him  and  a  clear  light.  Sucli  ob- 
jects appeared  involved  in  a  thick  mist.  During  the  following 
night,  the  pain  in  the  head  totally  deprived  him  of  sleep  ;  but  he 
had  no  constitutional  disturbance,  or  disposition  to  fevei-.  Next 
day,  he  was  much  the  same.  There  was  no  aotioa  of  the  iris  of 
either  eye,  on  exposure  to  various  degrees  of  light.  The  pupils 
remained  fixed,  in  a  state  of  permanent  contraction.  He  was, 
however,  still  able  to  perceive  when  he  was  brought  near  a  win- 
dow ;  but  this  was  all  he  could  make  out. 

A  blister  was  applied  behind  each  ear,  and  others  to  the  lateral 
parts  of  the  feet.  Small  doses  of  calomel  were  ordered  at  short 
intervals,  with  a  view  to  bring  his  system  under  the  mercurial  in- 
fluence. As  soon  as  the  blisters  began  to  operate  and  became  pain- 
ful, he  perceived  the  pain  in  the  head  and  affection  of  sight  re- 
lieved. By  the  time  they  were  dressed,  at  the  usual  period  of 
twenty-four  hours  after  their  application,  he  was  able  to  distinguish 
many  objects  with  tolerable  precision,  which  were  before  totally  in- 
visible. Dressings  of  an  irritating  kind  were  applied,  as  it  was 
deemed  necessary  to  keep  up  a  considerable  discharge  for  some 

*  Edinburgh  Medical  and  Surgical  Journal,  Vol.  xxv.  p.  37.    Edinburgh,  1826. 


678 

time.  It  was  also  directed,  that  his  feet  should  be  immersed  in 
warm  water,  morning  and  evening,  and  afterwards  wrapped  very 
warmly  in  flannels,  to  restore,  if  possible,  the  wonted  freeuess  of 
perspiration. 

Under  this  treatment,  the  patient  was  gradually  restored  to 
health,  losing  the  distressing  pain  in  his  head,  while  he  every  day 
found  his  sight  improve.  The  mercurial  course  affected  his  mouth 
rather  smartly,  and  under  its  influence  he  had  the  comfort  to  find 
himself  entirely  relieved  of  the  little  remaining  headach,  and  very 
nearly  the  w'hole  of  the  affection  of  his  eyes.  He  had  previously 
enjoyed  a  clearness  of  sight  very  rare  at  his  age,  and  after  his  re- 
covery, his  vision  became  nearly,  though  not  quite,  as  good  as  it  had 
been  before  the  suppression  of  the  perspiration  from  his  feet.  On 
leaving  the  infirmary,  he  was  recommended  to  wear  a  piece  of 
oiled  silk,  wrapped  round  each  foot,  with  a  view  to  encourage  the 
insensible  perspiration.* 

XI.  Amaurosis  from  Morhid  Changes  in  the    Optic  Nerves. 

That  variety  of  amaurosis  which  arises  from  some  morbid 
change  in  the  substance,  or  in  the  sheath  of  the  optic  nerve,  is,  ac- 
cording to  Beer,  developed  very  slowly,  and  rarely  in  both  eyes. 
It  is  attended  by  the  sensation  of  a  black  cloud,  which  seems  grad- 
ually to  become  m.ore  and  more  dense,  and  by  such  a  degree  of 
visus  defiguratus  as  is  extremely  distressing  to  the  patient.  He 
rarely  complains  of  much  pain,  either  in  the  eye  or  head,  but  only 
of  a  feeling  of  obtuse  pressure  in  the  posterior  part  of  the  orbit,  al- 
though not  the  slightest  degree  of  projection  of  the  eyeball  is  to  be 
observed.  Even  at  the  very  commencement,  the  pupil  is  extremely 
enlarged,  the  iris  completely  immovable,  and  the  pupillary  edge 
irregular.  Glaucoma  takes  place,  and  is  followed  by  glaucomatous 
cataract,  unaccompanied,  however,  by  any  varicose  state  of  the 
blood-vessels  of  the  eye.  At  last,  the  eyeball  becomes  sensibly 
smaller  than  natural,  without  becoming  absolutely  atrophic. 

The  following  are  some  of  the  morbid  changes  which  have  been 
detected  on  dissection  ;  induration  of  the  optic  nerve,  unnatural 
adhesion  between  it  and  its  sheath,  the  medullary  substance  of  the 
nerve  ash-co-oured  and  wasted,  hydatids  between  the  nerve  and 
its  sheath,  calculous  concretions  within  the  sheath.  Most  of  these 
changes  are,  no  doubt,  the  results  of  chronic  inflammation.  They 
are  often  complicated  with  disease  in  the  brain,  and  are  generally 
attended  by  disorganization  of  the  eyebalL  As  it  is  fully  ascer- 
tained, that  destruction  of  the  eye  is  frequently  the  cause  which 
leads  to  atrophy  and  other  diseased  states  of  the  optic  nerve,  it  is 
necessary  always  to  ascertain  whether  the  case  before  us  has  been 
one  of  disorganization  of  the  eye  from  inflammation,  leading  to 
atrophy  of  the  optic  nerve,  or  one  of  diseased  nerve  leading  to  am- 
aurosis and  atrophy  of  the  eye. 

*  Practical  Observations  in  Surgery  and  Morbid  Anatomy,  by  John  Howship  ;  p. 
135.     London  1816. 


679 

Case  1.  Mrs. ,  aged  83,  had  been  completely  blind  from 

amaurosis  for  thirty  years  before  her  decease  in  1817.  She  had 
also  been  subject  to  irregular  gout,  which  assumed  a  variety  of 
forms,  and  some  months  before  her  death  she  was  attacked  with 
palsy  of  one  side. 

On  opening  the  head,  aqueous  effusion  was  found  below  the 
tunica  arachnoidea,  and  in  both  ventricles.  One  part  of  the  cere- 
brum was  observed  to  be  of  a  pulpy  texture,  but  these  appearances 
were  most  probably  connected  with  the  recent  paralytic  attack,  and 
not  at  all  with  the  amaurotic.  All  the  nerves,  with  the  exception 
of  the  optic,  had  the  usual  appearance.  On  examining  the  mem- 
branous sheaths  of  these  nerves,  it  was  ascertained  that  their  me- 
dullary m,atter  had  been  completely  removed.  This  change  had 
taken  place  even  nearer  to  the  brain  than  where  the  nerves  cross 
each  other.  The  arteries  of  the  brain  were  in  most  parts  altered  in 
their  structure ;  their  coats  were  speckled  with  white  spots,  and 
their  texture  was  more  rigid  and  firm  than  natural.  Both  the 
carotids,  where  these  vessels  are  in  contact  with  the  optic  nerves  at 
the  foramina  optica,  were  found  to  be  remarkably  dilated,  suggest- 
ing the  idea  that  the  absorption  of  the  nerves  was  connected  with 
the  enlarged  state  of  the  arteries.  The  absorption,  however,  of  the 
optic  nerves  nearer  the  brain  could  not  be  accounted  for  on  this 
notion  ;  so  that  it  was  not  easy  to  conjecture  whether  the  enlarged 
state  of  the  vessels  was  the  cause,  or  the  effect,  of  the  absorption  of 
the  optic  nerves.  A  similar  tendency  to  enlargement  of  the  arte- 
ries was  noticed  where  the  cerebral  arteries  enter  the  cranium,  and 
perhaps  it  might  have  been  traced  in  other  situations,  if  a  more 
minute  search  had  been  made. 

The  twin-sister  of  this  lady  died  in  her  81st  year,  and  for  eight 
or  ten  years  before  her  death  had  been  also  completely  amaurotic. 
Though  her  general  health  was  more  entire  than  is  usual  at  such 
an  advanced  age,  she  had  completely  lost  not  only  her  sight,  but 
also  the  senses  of  smell,  taste,  and  hearing.  She  could  not  distin- 
guish animal  from  vegetable  food,  nor  one  sort  of  fluid  from^ 
another.     No  opportunity  was  obtained  of  inspection  after  death. 

Dr.  Brown,  who  communicates  these  interesting  particulars  to  Dr. 

Monteath,  states,  that  the  only  daughter  of  Mrs,  was  alive, 

and  had  been  totally  blind  from  amaurosis  for  several  years,  being 
then  in  her  56th  year.     Dr.  Monteath  adds,  that  he  had  been 

consulted  by  the  son  and  grandson  of  Mrs.  ,  both  of  whom 

had  weak  eyes.  The  grandson,  in  particular,  had  a  very  dis- 
tressing degree  of  congenital  amblyopia.  Any  exertion  of  his  eyes 
induced  temporary  blindness,  and  though  he  could  sometimes  see 
a  minute  object,  at  other  times  he  would  walk  directly  against  a 
table  or  a  chair.* 

Case  2.     A  person  of  the  name  of  Bardon,  aged  36,  was  ad- 

*  Notes  to  Weller's  Manual.    Vol.  ii.  p.  79.    Glasgow,  1821. 


680 

raifted  into  the  Hotel-Dieu  at  Paris,  on  the  8th  of  Sept.  1827". 
His  pupils  were  greatly  dilated,  the  right  being  still  slightly  niovabley 
the  left  not  at  all.  The  left  eye  was,  in  fact,  completely  lost ;  the 
right  just  served  for  discerning  large  objects,  without  enabling  the 
patient  to  distinguish  their  size,  form,  or  colour.  For  eight  years 
he  had  been  subject  to  violent  pains  in  the  head,  and  a  year  and 
a  half  before  his  admission  \ni<y  the  Hotel-Dien  had  been  obliged 
to  give  up  his  occupation,  which  required  him  to  be  frequently  em- 
ployed in  writing.  His  countenance  was  pale,  and  constitution 
lymphatic.  He  was  bled,  and  had  a  seton  inserted  in  the  neck, 
without  much  benefit.  Blistei's  were  next  applied  to  the  forehead 
and  temples,  followed  by  sensible  amendment,  so  that  in  three 
weeks,  he  could  distinctly  perceive  persons  passing  at  a  considera- 
ble distance.  The  same  means  were  continued,  and  the  patient 
remained  in  the  same  state  till  the  13th  of  November.  Upon  that 
day,  he  complained  of  headach,  and  severe  pains  in  the  eyes  and 
ears.  On  the  15th,  fifteen  leeches  were  applied  behind  the  ears  ; 
the  headach  subsided,  but  the  other  pains  continued.  On  the  21st, 
two  or  three  minutes  after  speaking  to  one  of  his  medical  attend- 
ants, he  suddenly  expired. 

In  the  interval  between  the  junction  of  the  optic  nerves  and  the 
pons  Varohi,  and  between  the  vessels  forming  the  circle  of  Willis, 
there  was  a  cyst,  the  size  of  a  small  hen's-egg,  partly  fibrous,  partly 
osseous,  filled  with  a  yellowish  substance,  mixed  with  blood,  about 
a  third  of  this  substance  being  solid  and  somewhat  resembling  a 
tubercle,  the  rest  fluid  and  oleaginous.  This  cyst  had  flattened 
and  almost  destroyed  the  optie  nerves.  Indeed,  what  remained  of 
these  nerves  adhered  along  their  inner  side  to  the  cyst,  by  some  re- 
mains of  altered  cerebral  substance,  and  anteriorly  lost  itself  upon 
the  osseous  part  corresponding  to  the  commissure  of  the  nerves. 
Farther  forward's,  the  nerves  were  found  in  a  wasted  state  passing 
into  the  orbits ;  but  between  this  their  anterior  portion  and  the 
posterior,  there  vx^as  no  other  continuity  than-  what  was  formed  by 
the  cyst.  There  was  no  trace  of  the  pituitary  gland,  its  situation 
being  entirely  occupied  by  the  cyst.  The  retina  within  the  eye 
was  thin,  reddish^  and  almost  transparent.* 

This  case  is  published  by  Majendie,  with  the  following  query 
prefixed  to  it.  Can  vision  he  preserved  rtotwitftstanding  the  de- 
struction of  the  optic  nerves  7  It  is  probable,  that  the  patient 
had  either  deceived  himself,  regarding  the  degree  of  vision,  which 
he  recovered  after  the  application  of  the  bhsters ;  or,  that  if  he 
was  actually  able  to  perceive  persons  passing,  as  is  stated  in  the 
case,  eight  days  before  his  death,  the  progress  of  the  disease  during 
that  period  had  been  exceedingly  rapid. 

*  Journal  de  Physiologic,  Tome  viii.  p.  28.    Paris;  1828. 


681 


XII.  Amaurosis  from.  Morbid  Form,ations  in  the  Brain. 

The  diseases  here  referred  to  are  tumours,  formed  by  thickening 
of  the  membranes  of  the  brain,   or  by  deposition  of  new  matter 
between  their  laminae,  or  on  their  surfaces  ;  also,   tubercles,  hyda- 
tids, and  fungous  growths.     The  reader  will  find  an  admirable 
account  of  the  symptoms  arising  from  these  various  states  of  dis- 
ease, in  Dr.  Abercrombie's  work  on  the  Brain.     He  states,  that 
there  is  not  sufficient  uniformity  in  the  symptoms,  to  enable  us  to 
refer  particular  symptoms  to  the  various  forms  of  the  morbid  affec- 
tions in  question.     The  principal  modifications  of  the  symptoms 
he  brings  under  seven  heads ;  viz.  1.  Long-continued  and  severe 
headach,  without  any  other  remarkable  symptom.     2.  After  some 
continuance  of  fixed  headach,  affections  of  the  senses,  speech,  and 
intellect.     3.  Headach,  affections   of  the  senses  and  convulsions. 
4.  Convulsions,  without  any  affection  of  the  senses.     5.  Paralysis. 
6.  Prominent   symptoms   in   the   digestive  organs.      7.  Vertigo, 
and  apoplectic  attacks.     The  cases  with  which  Dr.  Abercrombie 
has  illustrated  these  classes  of  symptoms  are  highly  interesting.     It 
must  not,  however,  be  supposed  that  these  classes  of  symptoms 
are  at  all  times  distinct,  and  never  mix  in  one  and  the  same  case. 
That  much  remains  to  be  done  in  regard  to  the  pathology  of  mor- 
bid formations  in  the  brain,  is  evident  from  the  fact  stated  by  Dr. 
Abercrombie,  that  tumours  are  sometimes  met  with  in  that  organ, 
which  have  produced  no  remarkable  symptoms,  while  in  other 
subjects,  tumours  in  the  same  situation,  and  of  no  larger  size,  have 
been  accompanied  by  blindness,  convulsions,  or  paralysis. 

Beer  tells  us,  that  the  amaurosis  resulting  from  morbid  for- 
mations in  the  brain,  generally  attacks  both  eyes  at  once.  The 
bhndness  is  developed  very  slowly,  not  with  the  sensation  of  a  black 
cloud,  but  with  visus  defiguratus,  indistinctness  and  confusion  in 
the  appearance  of  all  objects.  Along  with  these  symptoms  there 
are  repeated  attacks  of  giddiness,  distressing  photopsia,  and  intoler- 
ance of  light.  The  pupil,  for  a  time,  is  contracted;  the  blood- 
vessels on  the  surface  of  the  eye  turgescent ;  the  motions  of  the 
eye  and  eyelids  at  first  convulsive,  but  afterwards  palsied,  so  that 
the  eye  is  turned  imraoveably  to  one  side,  and  the  upper  eyelid 
cannot  be  raised.  The  pupil  now  becomes  dilated,  and  vision  ex- 
tinguished. The  headach  generally  goes  on  increasing,  and  pain 
is  also  felt  in  the  vertebral  column.  The  pain  is  not  uniform  in 
degree,  but  remits  at  times,  and  then  increases  with  such  violence 
that  the  patient  almost  loses  his  reason.  There  takes  place,  at  last,  a 
permanent  disorder  both  of  the  remaining  external  senses  and  of  the 
mental  faculties.  Hearing  is  the  first  of  the  remaining  external 
senses  which  fail ;  then  follows  smell  or  taste,  and  sometimes  both 
about  the  same  time.  At  last,  the  patient  loses  his  memory,  and 
sinks  into  general  insensibility,  or  becomes  maniacal.  An  attack 
of  palsy  generally  closes  the  scene. 
86 


682 

Causes.  Morbid  formations  in  the  brain  rarely  occur  except  in 
persons  of  cachectic  constitutions.  Their  exciting  causes  are  blows 
on  the  head,  fatigue,  cold,  and  the  like. 

Treatment.  In  regard  to  the  treatment  of  amaurosis,  attended 
with  symptoms  leading  us  to  suspect  the  existence  of  some  morbid 
formation  in  the  brain,  it  is  important  to  observe,  that  such  cases 
ought  by  no  means  to  be  considered  as  r.tterly  hopeless.  Many 
cases  of  this  kind  have  their  origin  in  inflammatory  action  ;  and, 
by  proper  treatment,  we  may  often  impede  their  progress,  prolong 
the  life  of  the  patient,  render  him  more  comfortable,  and  even  pre- 
serve a  certain  degree  of  vision.  The  treatment  will  consist  in 
keeping  the  system  low,  by  evacuations  and  spare  diet,  in  the  cau- 
tious use  of  alteratives,  and  especially  of  mercury  and  arsenic,  in 
cold  applications  to  the  head,  issues  or  setons  in  the  neck,  and  the 
.careful  avoidance  of  all  causes  of  excitement. 

Case  1.  Dr.  Abercrombie  records  the  case  of  a  man,  aged  47, 
whose  complaints  began  in  May,  1816,  with  headach,  and  weight 
in  the  head,  aggravated  by  stooping,  and  increasing  gradually, 
notwithstanding  copious  evacuations.  In  August,  his  sight  began 
to  fail,  with  giddiness ;  in  September,  he  could  see  objects  only  in 
a  very  strong  light ;  in  December,  perfect  bhndness,  the  pain  still 
continuing  constant  and  severe  ;  in  the  middle  of  January,  stupor 
and  forgetfulness,  followed,  on  the  31st  of  that  month,  by  coma 
and  death. 

A  tumour,  the  size  of  a  large  egg,  was  found  attached  to  the 
tentorium,  in  such  a  manner,  that  part  lay  above,  and  part  below 
it ;  the  falx  likewise  entering  into  its  substance  above.  Internally 
it  was  firm,  resembling  somewhat  the  structure  of  the  kidney. 
There  were  four  ounces  of  fluid  in  the  ventricles.* 

Case  2.  The  following  case  was  communicated  to  Dr.  Aber- 
crombie by  Dr.  Hay.  A  girl,  aged  eleven,  had  long  been  liable  to 
headach,  with  weakness  of  sight,  and  a  peculiar  tenderness  of  the 
integuments  of  the  head.  In  autumn  1814,  she  received  an  injury 
on  the  forehead  from  a  fall,  and  from  that  time  suffered  much  from 
headach,  with  frequent  epistaxis.  In  the  end  of  December,  the 
headach  increased,  with  fever,  intolerance  of  light  and  sound, 
squinting  and  convulsive  paroxysms,  which,  for  some  time,  recurred 
every  half  hour.  In  March,  1815,  she  improved  remarkably,  and 
for  nearly  a  year  continued  better  in  regard  to  the  head  symptoms, 
but  affected  with  scrofulous  sores  on  the  neck  and  leg.  In  May, 
1816,  the  headach  increased,  with  impatience  of  light  and  sound, 
squinting,  and  gradual  failure  of  sight,  till  at  last  in  July  she  be- 
came blind.  She  died  in  October,  her  intellect  having  continued 
unimpaired.  She  also  retained  remarkable  acuteness  of  hearing, 
and  intolerance  of  sound  to  the  last. 

On  dissection,  a  tumour,  of  the  size  of  a  walnut,  was  found  rest- 

*  Pathological  and  Practical  Researches  on  Diseasesof  the  Brain,  p.  461.  Edin* 
1829. 


683 

ing  on  the  sella  Turcica,  and  compressing  the  junction  of  the  optic 
nerves.  It  was  composed  of  a  medullary  substance  of  a  yellowish 
colour,  and  was  covered  by  a  thin  and  delicate  membrane.* 

Case  3.  Mr,  Morrah  relates  the  case  of  Elizabeth  Lindup, 
nineteen  years  of  age,  of  robust  make,  and  general  good  health, 
who  for  three  years  had  continued  to  complain  of  pain  and  swim- 
ming of  her  head,  increased  by  motion,  and  particularly  by  stoop- 
ing. These  symptoms  continued  with  occasional  exacerbations, 
accompanied  by  irritation  of  the  stomach,  and  a  suffusion  of  the 
eyes  such  as  is  produced  by  crying,  till  the  22d  of  April,  1810  ; 
when,  during  her  occupation  of  cooking  a  dinner  she  was  seized 
without  any  previous  warning,  with  a  fit,  during  which  she  had 
no  convulsions,  but  lay  motionless,  her  inspirations  being  very  long 
and  deep,  and  gradually  becoming  less  so  till  she  recovered.  This 
happened  immediately  after  the  completion  of  the  menstrual  flux, 
and  lasted  some  minutes.  Mr.  Morrah  saw  her  before  the  fit  was 
quite  over,  and  was  particularly  struck  with  the  complaint  she 
made  of  an  acute  fixed  pain  of  the  head,  and  with  the  ferrety  ap- 
pearance of  the  eyes.  One  month  from  this  time  she  had  another 
fit,  which  seized  her  so  unexpectedly,  that  she  dropped  with  a  pan 
of  milk  in  her  hand ;  and  from  this  time,  till  the  20th  of  August, 
she  had  a  paroxysm  every  third  week.  Each  of  these  paroxysms 
might  be  said  to  consist  of  two  fits,  one  in  the  evening,  from  which 
she  very  imperfectly  recovered,  till  after  a  second,  next  morning, 
after  which  she  continued  free  from  any  fit  for  three  weeks.  On 
the  20th  of  August  she  had  three  fits  in  one  day,  accompanied  by 
a  considerable  derangement  of  stomach,  and  by  screaming,  and 
other  indications  of  great  suffering,  amounting  almost  to  delirium. 
A  succession  of  these  distressing  attacks,  increasing  in  severity,  and 
with  stupor  intervening,  continued  till  the  middle  of  September, 
when  she  had  nearly  lost  her  hearing.  Shortly  afterwards  she 
lost  the  sight  of  her  right  eye,  and  in  fourteen  days  more,  that  of 
her  left.  Her  smell  was  completely  gone,  the  olfactory  nerves  be- 
ing insensible  even  to  the  stimulus  of  hartshorn  ;  her  speech  and 
power  of  deglutition  were  very  much  impaired,  and  her  left  side,  of 
which  she  had  previously  complained  as  being  affected  with  rigors, 
became  paralytic.  On  Friday,  the  7th  of  December,  she  fell  into 
an  apopletic  stupor,  which  continued  till  the  Thursday  morning 
following ;  during  which  period  she  neither  spoke,  nor  took  nour- 
ishment. At  that  time  she  roused  up,  spoke,  and  swallowed  some 
refreshment,  but  soon  relapsed  into  the  former  state ;  and  on  Fri- 
day evening,  the  14th  of  December,  she  died.  During  the  whole 
period,  with  the  exception  of  October,  she  menstruated  regularly. 
The  pulse,  till  towards  the  conclusion,  was  not  affected ;  there  was 
ho  increase  of  heat,  the  bowels  were  rather  costive,  but  easily  acted 

*  Pathological  and  Practical  Researches  on  Diseases  of  the  Brain,  p.  462.    Edin. 
1829. 


6S4 

upon  ;  and  the  bladder  did  its  office.  At  all  times,  however,  the 
girl  laboured  under  a  degree  of  nervous  irritabillity,  unaccountable 
in  a  person  of  such  general  good  health  and  robust  organization. 

On  dissection,  the  vessels  of  the  dura  mater  appeared  rather 
more  turgid  than  usual.  On  removing  the  dura  mater,  the  pia 
mater  was  seen  elevated  over  the  right  hemisphere  by  a  tumour, 
which  was  found  to  be  a  hydatid,  about  three  inches  long  by  two 
inches  broad,  imbedded  in  the  substance  of  the  brain,  from  which 
it  was  liberally  supplied  with  numerous  minute  blood  vessels.  The 
left  ventricle  contained  a  little  more  fluid  than  is  usually  found  in 
a  healthy  subject ;  the  right  had  hardly  any,  being  compressed  by 
the  tumour.* 

Case  4.  Miss  M.  A.  was  afflicted  with  severe  headach,  in  the 
early  part  of  1820,  being  then  in  her  seventeenth  year.  She  was 
of  a  delicate  frame,  light  hair  and  eyes,  fair  complexion,  and  mild 
and  cheerful  disposition.  She  had  previously  enjoyed  good  health, 
menstruated  regularly,  had  not  received  any  blow  or  injury,  and 
knew  of  no  cause  to  which  her  complaint  could  be  assigned.  Com- 
mon means  afforded  relief,  and  she  went  down  into  Cheshire  for 
four  months  during  the  summer,  where  she  was  in  the  habit  of 
taking  daily  exercise,  and  on  one  occasion  walked  10  miles  with- 
out much  inconvenience,  but  was  never  entirely  free  from  head- 
ach. Shortly  after  her  return  to  town,  the  pain  again  became 
very  distressing,  and  she  again  derived  benefit  from  medicines,  and 
the  application  of  a  blister  to  the  neck. 

In  January,  1821,  in  consequence  of  a  severe  return  of  pain, 
leeches  were  applied  to  the  forehead,  after  which  she  had  a  long 
interval  of  comparative  ease.  In  February,  she  was  at  a  ball, 
danced  for  several  hours,  and  appeared  to  enjoy  herself  much  ;  nor 
did  she  apply  for  farther  advice  till  the  30th  of  May  following. 
Her  symptoms  then  became  rapidly  worse,  and  the  pain  of  the 
head  assumed  a  more  serious  character.  It  was  usually  referred  to 
the  right  temple,  and  she  experienced  a  regular  exacerbation  every 
morning  to  such  a  degree,  that  in  agony  she  would  roll  about  the 
bed  for  an  hour  or  two,  after  which  the  pain  would  gradually  sub- 
side, and  continue  tolerable  during  the  day.  She  was  affected  with 
vertigo,  occasional  syncope,  great  dread  of  imaginary  objects,  a  state 
of  high  nervous  irritation,  dulness  of  hearing,  and  indistinct  vision. 
She  became  short-sighted ;  objects  appeared  to  her  larger  than 
natural,  and  at  times  she  was  totally  blind  for  several  seconds. 
She  had  quickness  of  pulse,  heat  of  skin,  violent  pain  in  the  stomach, 
sickness  and  vomiting.  Severe  pains,  unattended  with  any  external 
appearance  of  inflammation,  attacked  in  succession  various  parts  of 
the  body  ;  at  one  time  the  throat,  occasioning  an  extreme  difficulty 
of  deglutition,  at  another  the  chest,  impeding  the  respiration,  at 
another,  different  parts  of  the  spine,  particularly  towards  the  neck, 

♦  Medico-Chirurgical  Transactions,  "Vol.  ii.  p.  262.    London,  1823. 


685 

also  the  knees,  the  ancles,  and  the  wrists.  Blisters,  cold  applica- 
tions to  the  head,  mercury  in  small  doses,  not  to  the  extent  of  sali- 
vation, and  various  other  means,  were  tried,  but  with  little  or  no 
relief.  Her  health  declined  fast,  and  she  became  much  emaciated 
from  the  constant  vomiting. 

On  the  31st  of  August,  1821,  she  was  attacked,  while  in  bed, 
with  a  fit  of  strong  convulsions,  attended  with  strabismus  and 
screaming,  which  lasted  about  half  an  hour,  and  left  her  in  a  state 
of  stupor.  Next  day  she  had  lost  all  power  over  the  body,  and 
could  not  raise  herself,  or  even  turn  from  side  to  side  in  bed  ;  her 
legs  and  arras  she  could  still  move  a  little  ;  her  sight,  which,  though 
imperfect,  had  hitherto  enabled  her  to  discern  objects,  was  now  so 
far  lost,  that  she  could  perceive  only  the  difference  between  light 
and  darkness.  The  pupils  were  much  dilated,  but  still  slightly 
affected  by  light.  Her  deafness  also  was  greatly  increased.  The 
failure  in  sight  and  hearing  occurred  first  on  the  left  side,  being 
opposite  to  that  in  which  the  pain  was  originally  fixed.  The  bowels 
weie  obstinately  costive ;  the  vomiting  and  pain  of  stomach  con- 
tinued ',  the  pain  of  the  head  was  intense ;  the  pulse  quick,  her 
respiration  hurried,  skin  hot  and  dry,  sleep  tranquil  and  with- 
out stertor.  In  the  course  of  a  few  days  she  had  a  repetition  of  the 
same  kind  of  fit ;  which  continued  to  return  with  more  or  less  fre- 
quency and  severity,  till  within  a  short  period  of  her  death,  gene- 
rally influenced,  however,  by  the  state  of  the  alimentary  canal. 
Sometimes  she  had  five  or  six  in  a  day,  and  occasionally  she  would 
pass  several  days  without  any  fit.  They  usually  came  on  without 
warning;  sometimes  they  appeared  to  be  produced  by  slight  exer- 
tion. Besides  the  general  convulsive  attacks,  she  was  subject  to 
spasmodic  twitchings  and  startings  of  different  parts  of  the  body. 
Sight  and  hearing  were  soon  lost  altogether ;  smell  was  entirely 
lost,  and  taste,  if  any  remained,  was  very  imperfect-  She  expressed 
a  desire  for  particular  articles  of  food,  but  alwa5'^s  complained  of 
their  being  insipid,  and  could  seldom  tell  what  she  was  eating. 

Being  deprived  of  the  use  of  all  the  organs  of  sense,  except  touch, 
the  only  mode  of  communication  that  could  be  devised  was  the 
common  method  of  talking  with  the  fingers,  the  person  with  whom 
she  was  conversing  indicating  each  letter  upon  her  fingers.  She 
was  soon  able  to  distinguish,  by  the  touch,  every  person  with  whom 
she  was  in  the  habit  of  talking,  and  acquired  considerable  facility 
in  this  mode  of  conversing,  guessing  the  words  before  they  were 
half-spelt.  She  would  thus  keep  one  or  other  of  her  attendants 
constantly  employed  when  awake.  She  was  anxious  to  amuse 
herself  with  some  kind  of  manual  occupation,  but  her  arms  were 
so  feeble  that  she  could  not  bear  the  fatigue.  Her  intellect  was 
unimpaired,  except  when  under  the  influence  of  the  fits.  She  ap- 
peared to  be  aware  of  her  hopeless  condition,  and  desired  that  her 
head  might  be  opened  after  death.  She  evinced  great  patience 
under  her  sufferings,  and  was  even  cheerful  when  the  pain  was 


686 

moderate.  She  was  seldom,  however,  when  awake,  free  from  in- 
tense pain  in  the  head,  of  a  lancinating  or  throbbing  kind,  not  con- 
fined to  any  particular  part.  The  pain  at  the  upper  and  lower 
part  of  the  spine,  the  sensation  of  extreme  coldness  down  the  back, 
and  the  pain  in  the  right  and  afterwards  in  the  left  breast,  were 
also  at  times  exceedingly  distressing.  The  face  was  often  swelled, 
and  at  other  times  quite  shrunk.  She  rarely  complained  of  cold, 
excepting  down  the  spine.  The  cheeks  were  subject  to  partial 
flushings,  the  heat  of  skin  was  frequently  oppressive,  and  the  itching 
at  times  intolerable.  The  tongue  was  occasionally  furred,  but 
generally  clean.  She  had  no  thirst.  The  appetite,  after  the  vom- 
iting ceased,  became  almost  insatiable,  and  she  recovered  flesh. 
The  eyes  retained  their  lustre,  but  were  quite  insensible  to  light, 
and  the  pupils  were  fully  dilated. 

Subsequently  she  had  repeated  attacks  of  bilious  vomiting,  re- 
ducing her  each  time  to  a  state  of  extreme  debility,  from  which 
she  as  often  rallied  in  a  surprising  manner.  The  bowels  were 
obstinately  torpid,  seldom  acting  without  the  aid  of  cathartics. 
She  once  went  fourteen  days  v/ithout  an  evacuation.  Her  symp- 
toms were  invariably  aggravated  when  the  bowels  were  consti- 
pated. The  catarnenia  ceased  to  appear,  after  she  was  confined  to 
bed.  Her  respiration  was  natural  and  easy ;  speech  unaltered ; 
voice  clear  and  distinct ;  pulse  from  80  to  100,  small  and  gener- 
ally weak  ;  sleep  very  easy  and  undisturbed,  except  by  her  crying 
out  to  be  turned,  after  which  she  would  fall  asleep  again  directly. 
She  could  lie  on  her  back,  or  on  either  side,  but  was  unable  to 
rest  in  the  same  position  above  half  an  hour  at  a  time,  so  that  she 
required  some  person  constantly  in  attendance  to  turn  her ;  and 
if  this  was  not  done,  as  soon  as  asked  for,  she  often  went  into  a 
fit.  She  never  recovered  the  power  of  her  body,  nor  could  she 
move  her  head  in  the  least  degree  ;  but  her  sense  of  touch  con- 
tinued perfect.  Several  attempts  were  made  to  raise  her  gradual- 
ly in  bed,  but  they  always  produced  considerable  pain,  and,  if 
persisted  in,  brought  on  a  fit.  The  medicines  exhibited  were  in- 
tended merely  to  relieve  her  sufferings,  except  an  attempt  which 
w^as  made  to  affect  the  system  with  meicury  ;  but  the  fits  increased 
so  much  during  its  use,  that  it  was  discontinued. 

The  above  symptoms  continued  with  more  or  less  urgency  till 
February,  1823,  when  her  powers  began  to  fail  altogether,  the 
stomach  rejecting  every  kind  of  food.  No  evacuation  could  be  pro- 
cured from  the  bowels,  without  the  aid  of  injections ;  the  whole 
muscular  system  seemed  to  lose  its  tone :  the  limbs  were  drawn 
into  a  semiflexed  position,  and  she  had  scarcely  strength  to  move 
them ;  the  lips  were  half  closed,  the  mouth  full  of  aphthous  ulce- 
rations, and  the  teeth  covered  with  sordes  ;  the  features  were  dis- 
torted ;  she  slept  with  her  eyehds  half  open  ;  the  eyes  became 
dim  ;  inflammation  came  on  in  the  left  eye,  which  proceeded  to 
ulceration,  and  opacity  of  the  cornea.     She  expressed  no  pain,  and 


687 

was  not  even  aware  that  the  eye  was  affected.  The  urine  and 
faeces  were  passed  involuntarily.  She  could  not  swallow  any  food 
unless  it  was  reduced  to  a  liquid  form,  and  then  only  with  difficul- 
ty. She  had  a  troublesome  cough,  which,  from  her  extreme  de- 
bility, frequently  threatened  suffocation.  Pain  in  the  head  con- 
tinued to  distress  her,  but  the  fits  were  less  frequent,  and  appeared 
incapable  of  producing  the  same  convulsive  action,  from  want  of 
power  in  the  muscles.  Her  mental  faculties  also  declined  ;  she 
talked  very  little,  and  only  of  her  complaints.  Her  pulse  was  so 
feeble  as  to  be  scarcely  perceptible.  She  still  breathed  freely,  and 
slept  much.  In  September,  a  slight  diarrhoea  came  on.  She 
could  now  take  scarcely  any  sustenance,  and  had  become  so  much 
emaciated  that  the  skin  was  excoriated  in  several  places  from^pres- 
sure.  She  died  on  the  5th  of  October,  1823,  having  lingered 
more  than  two  years  from  the  first  attack  of  convulsions,  and  near- 
ly four  years  from  the  commencement  of  the  headach. 

The  scalp  was  shghtly  (edematous.  The  bones  of  the  cranium 
were  extraordinarily  thin,  and  several  short  spicula  projected  in- 
wards, from  the  posterior  part  of  each  parietal  bone.  The  mem- 
branes covering  the  brain  were  free  from  disease  ;  the  substance  of 
the  cerebrum  rather  softer  than  usual ;  from  eight  to  ten  ounces 
of  fluid  in  the  ventricles  ;  the  membrane  lining  the  ventricles  of  a 
dingy  yellow  colour.  The  thalami  nervorum  opticorum  were 
somewhat  enlarged,  and  entirely  converted  into  a  fungous  disease, 
which  Mr.  Hunter,  the  narrator  of  the  case,  considers  to  have  been 
of  the  nature  of  fungus  heematodes.  A  longitudinal  section  through 
one  of  the  thalami  presented  exactly  the  appearance  of  a  portion  of 
coagulated  blood.  The  corpora  striata  were  not  affected,  but  the 
disease  extended  into  the  adjacent  parts  of  the  cerebrum  and  cere- 
bellum below,  and  also  to  the  lower  and  posterior  edge  of  the  fal^i; 
major.  The  optic  nerves  were  of  a  darker  colour  than  usual,  but 
did  not  appear  to  be  altered  in  texture.  The  other  cerebral  nerves 
presented  no  deviation  from  their  natural  structure.  The  spinal 
marrow,  as  far  as  could  be  traced  through  the  foramen  magnum, 
was  perfectly  healthy.  There  were  several  sharp  ridges  of  bone 
at  the  basis  of  the  cranium,  and  the  irregularities  were  all  very 
strongly  marked.  No  diseased  appearance  was  found  in  the  tho- 
rax, nor  abdomeUj  except  a  number  of  small  biUary  concretions.* 

Xin.  Amaurosis  from  Morbid  Changes  in  the  Membranes:,  or 
in  the  Bones  of  the  Cranium,. 

There  are  various  states  of  the  dura  mater,  and  of  the  bones  of 
the  skull,  capable  of  inducing  amaurosis  ;  such  as,  ossifications  of 
the  dura  mater,  especially  when  they  are  in  the  form  of  sharp  spi- 
culae,  and  exostoses  proceeding  from  the  inner  table  of  the  skull. 

The  symptoms  arising  from  these  morbid  changes  are  exceeding- 

*  Medico-Chirurgical  TransactionSj  Vol.  xiii.  p.  88.    London,  1825. 


688 

ly  similar  to  those  already  described  as  attendant  on  diseased  for- 
mations within  the  cranium.  In  many  of  the  patients  who  labour 
under  the  present  variety  of  amaurosis,  there  takes  place  at  last  a 
protrusion  of  the  eye  out  of  the  orbit;  a  symptom  indicative  of 
great  derangement  in  the  bones  forming  the  basis  of  the  cranium, 
of  the  dura  mater  covering  the  sella  Turcica,  or  of  the  upper  part 
of  the  orbit. 

The  morbid  changes  of  the  bones,  which  induce  amaurosis,  are 
found  chiefly  in  the  basis  of  the  cranium.  In  these  cases,  caries  is 
sometimes  met  with,  but  much  more  frequently  exostosis  of  differ- 
ent forms.  In  some  instances,  innumerable  spiculse  of  bone  project 
into  the  cavity  of  the  cranium,  so  sharp  that  they  readily  wound 
the  finger.  Beer  preserved  the  skull  of  a  lady,  who  had  been  to- 
tally blind,  and  for  some  weeks  before  her  death  unconscious,  in 
which  there  was  scarcely  any  part  within  the  cranium  which  was 
not  studded  with  such  sharp  exostoses.  In  such  cases,  the  bones 
are  generally  very  thin,  the  diploe  being  almost  completel}'^  wanting. 
In  an  amaurotic  boy,  who,  for  a  short  time  before  his  death,  was 
insane,  Beer  found,  on  dissection,  a  spine,  of  considerable  length, 
by  the  side  of  the  sella  Turcica,  which  had  perforated  the  optic 
nerves  at  their  junction. 

There  is  a  set  of  cases,  described  by  Sir  Everard  Home,*  and 
attributed  by  him  to  the  spread  of  inflammation  from  the  dura  ma- 
ter to  the  pericranium,  which  are  attended  by  the  symptoms  com- 
mon to  pressure  on  the  brain  from  other  causes,  and  amongst 
these  by  amaurosis,  and  which  are  relieved  by  cutting  down  upon 
the  cranium,  so  as  to  remove  the  tension  of  the  parts  over  it.  In 
one  fatal  case  of  this  kind,  he  found  the  pericranium  thickened  in- 
to a  mass  of  a  fibrous  bony  texture ;  and  corresponding  to  this 
part,  internally,  there  was  a  similar  thickening  and  induration  of 
the  dura  mater.  Most  of  the  cases  referred  to  had  been  treated  by 
long  courses  of  mercury  without  benefit,  in  some  of  them  with 
aggravation  of  the  symptoms.  Sir  E.  Home  considers  the  disease 
as  beginning  in  the  dura  mater.  Dr.  Abercrombie  thinks  it  more 
likely  to  commence  in  the  pericranium  j  as  it  has  frequently  been 
cured  simpl)'^  by  cutting  down  to  the  bone.  In  the  progress  of 
neglected  cases,  both  the  skull  and  the  dura  mater  become  affected. 
As  in  most  of  the  cases  related  by  Sir  E.  Home,  the  patients  had 
previously  used  mercury  in  considerable  quantity,  he  concludes 
that  probably  the  effects  of  that  medicine  on  the  constitution  pre- 
dispose to  this  particular  disease. 

Those  who  have  suffered  from  rachitis  in  youth,  from  syphilis, 
or  from  gout  in  middle  age,  are  more  liable  than  others  to  the  pre- 
sent species  of  amaurosis. 

It  is  also  worthy  of  remark,  that  in  all  the  cases  mentioned  by 
Beer,  it  appears  that  the  complaint  in  the  head  and  eyes  began  af- 

*  Transactions  of  a  Society  for  the   Improvement  of  Medical  and  Chirurgical  j 
Knowledge,  Vol.  iii.  p.  122.    London,  1812. 


>       689 

ter  sudden  cooling  of  the  head,  followed  by  rheumatism,  which 
though  slight  in  its  commencement,  had  fixed  itself  in  the  fibrous 
covering  of  the  skull. 

The  prognosis  in  this  kind  of  amaurosis  is,  I  need  scarcely  say, 
extremely  unfavourable.  The  gradual  development  of  complete 
blindness,  and  not  only  death,  but  a  very  mournful  death,  is  to  be 
dreaded.  Nor  does  the  heahng  art  possess  any  means  which  can 
be  effectually  employed  in  diminishing,  much  less  removing,  the 
organic  changes  upon  which  the  disease  depends,  except  perhaps 
in  one  or  two  cases.  These  cases  are  when  the  symptoms  evident- 
ly originate  in  some  constitutional  disorder,  and  especially  in  syph- 
ilis. 

Case  1.  The  following  case  is  one  of  those  related  by  Sir  Ever- 
ard  Home. 

A.  B.,  aged  21,  in  the  year  1792,  had  some  venereal  symptoms, 
for  which  he  underwent  a  course  of  mercury.  The  symptoms 
were  removed,  but  he  was  ever  afterwards  subject  to  attacks  of  gid- 
diness, attended  w^ith  much  general  bodily  uneasiness,  and  a  re- 
markable degree  of  dejection  of  spirits.  These  attacks  occurred  at 
longer  or  shorter  intervals,  and  appeared  to  depend  very  much  on 
the  state  of  his  bowels.  He  was  naturally  of  a  very  costive  habit, 
in  consequence  of  which  he  took  frequent  doses  of  calomel.  By 
persevering  in  this  practice,  the  above-mentioned  symptoms  became 
less,  though  they  were  never  entirely  removed.  In  November, 
1806,  he  had  a  chancre  on  the  glans  penis,  for  which  he  took  hy- 
drargyrus  calcinatus,  and  confined  himself  to  the  house.  His 
mouth  became  sore,  and  the  chancre  healed  ;  but  he  was  soon 
after  attacked  with  a  severe  pain  in  the  right  side  of  his  head,  at- 
tended with  a  tumefaction  of  the  scalp  in  that  part.  The  pain 
was  so  severe  as  to  prevent  his  sleeping,  and  at  times  his  sight  and 
hearing  were  considerably  impaired.  At  the  end  of  six  weeks  he 
left  off  the  mercury  ;  but  the  symptoms  did  not  abate. 

On  the  29th  of  December  he  caught  cold,  and  the  symptoms  be- 
came much  aggravated.  On  the  2d  of  January,  an  abscess  burst 
in  his  right  ear,  the  discharge  from  which  continued  for  two  or  three 
days.  The  pain  and  swelling  were  now  diminished,  but  it  was 
found  that  his  mouth  was  drawn  to  the  left  side.  In  consequence 
of  this  paralytic  affection,  he  was  kept  low,  and  in  three  weeks  it 
went  off. 

In  a  week  after  the  bursting  of  this  abcess,  the  pain  became  as 
severe  as  before,  and  he  now  referred  it  to  the  left  side  of  the  head, 
over  the  parietal  bone.  The  pericranium  of  that  side  was  much 
tumefied.  About  the  14th  of  March,  these  symptoms  were  much 
aggravated  ;  and  on  the  17th,  he  became  deaf.  The  pain  was  so 
severe,  that  he  could  hardly  sit  up.  Sir  E.  Home  made  an  inci- 
sion down  to  the  parietal  bone.  The  pericranium  was  found  ex- 
tremely thickened  and  tender,  so  that  the  operation  caused  unusual 
pain.  He  experienced  immediate  relief,  and  slept  well  at  night, 
87 


690 

which  he  had  not  done  during  the  whole  progress  of  his  complaint. 
On  the  22d  of  March,  an  abscess  burst  in  his  right  ear,  and  dis- 
charged for  two  or  three  days.  In  the  course  of  a  week  after  the 
operation,  the  pain  and  tumefaction  subsided ;  but  he  continued 
deaf,  and  complained  of  a  noise  and  singing  in  his  head.  The 
wound  was  dressed  at  first  with  dry  lint,  afterwards  with  lint  moist- 
ened with  diluted  nitrous  acid.  In  two  months,  a  portion  of  bone, 
of  the  size  of  a  sixpence,  exfoliated.  In  six  weeks  more,  a  similar 
exfoHation  took  place ;  and  after  this  the  wound  was  allowed  to 
heal.  The  patient's  general  health  improved,  so  as  to  become  better  in 
every  respect  than  it  had  been  for  several  years  before  ;  but  he  con- 
tinued deaf,  and  troubled  with  an  incessant  noise  in  his  head. 
There  was  no  return  of  his  headachs.* 

Case  2.  The  following  case,  related  by  the  late  Mr.  Wilson,  of 
London,  shows  what  may  sometimes  be  done,  even  in  circumstances 
which  might  appear  almost  desperate. 

In  November,  1806,  Mr.  Wilson  was  requested  by  a  surgeon  of 
his  acquaintance  to  visit  a  gentleman,  who  had  been  affected  with 
a  long  and  severe  illness.  Mr.  W.  received  the  following  account 
of  the  case. 

In  the  spring  of  1803,  when  influenza  was  very  prevalent,  Mr. 
C,  a  muscular  man,  about  28  years  of  age,  and  of  rather  a  sanguine- 
ous temperament,  was  attacked  with  a  very  severe  deep-seated  pain 
in  the  orbit  of  the  left  eye.  A  physician  of  eminence  was  consulted, 
by  whom  a  rigidly  antiphlogistic  plan  was  recommended.  This 
was  persevered  in  for  a  considerable  time  without  benefit.  The 
case  was  then  deemed  nervous,  and  medicines  adapted  for  the  rehef 
of  nervous  diseases  were  employed  in  large  quantities.  The  pa- 
tient was  ordered  to  remove  to  Hampstead  for  the  benefit  of  the  air. 
This  plan  not  succeeding,  other  medical  opinions  were  taken,  and 
various  remedies  tried  ;  but  the  patient  gradually  became  worse. 
The  sense  of  hearing  in  the  left  ear  was  now  totally  lost.  The  leva- 
tor of  the  left  upper  eyelid  became  paralyzed,  and  a  great  degree  of 
strabismus  was  produced  by  the  rectus  externus  having  also  lost  its 
power.  The  pupil  of  the  left  eye  became  much  and  constantly 
dilated,  and  the  sight  of  that  eye  was  lost.  The  right  angle  of  the 
mouth  was  permanently  drawn  to  the  right  side.  An  extreme 
hoarseness  took  place,  and  his  articulation  became  so  indistinct  that 
he  could  not  be  understood  even  by  his  friends.  He  lost  the  power 
of  swallowing  solids,  and  swallowed  fluids  with  very  great  diflficulty, 
as  the  attempt  brought  on  a  distressing  sense  of  suffocation.  A 
vessel  was  constantly  placed  at  his  side  to  receive  the  saliva,  which 
he  could  neither  swallow  nor  eject  from  his  mouth,  and  which  he 
therefore  endeavoured  to  push  out  with  his  tongue.  His  bowels 
were  most  obstinately  constipated,  requiring  the  frequent  use  of  dras- 
tic purges. 

*  Transactions  of  a  Society  for  the  Improvement  of  Medical  and  Chirurgical  Knowl- 
edge, Vol.  iii.  p.  146.     London,  181 2. 


691 

j  Upon  visiting-  the  patient,  Mr.  Wilson  found  his  right  hand  and 
.'drm  folded  up,  and,  with  the  leg  of  the  same  side,  in  a  state  of  com- 
plete paralysis.  Very  violent  pain  in  the  orbit  of  the  left  eye  still 
continued,  and  there  was  also  considerable  pain  in  the  vertebrae  of 
the  neck,  and  at  the'  top  of  the  shoulder.  When  in  bed,  he 
could  not  raise  his  head  from  the  pillow ;  he  could  scarcely 
sleep  at  all,  and  had  no  respite  from  excruciating  pain ;  in 
short,  his  dissolution  was  hourly  expected.  Mr.  W.  learned  also, 
that  before  the  commencement  of  the  disease,  he  had  had  at  two  or 
three  different  times,  chancres  and  incipient  buboes,  and  that  for 
these  he  had  used  mercury,  until  the  symptoms  disappeared,  and 
the  surgeon  who  attended  him  pronounced  his  cure  to  be  complete. 
In  the  summer  preceding  his  illness,  he  had  strained  his  back  in 
leaping  ;  a  short  time  after  which,  a  bubo  formed  in  the  right  groin. 
This  was  particularly  attended  to,  under  the  supposition  that  it 
might  prove  venereal.  It  suppurated,  and  healed  without  mercury 
having  been  used. 

Observing  something  particular  in  the  figure  of  one  of  his  legs, 
Mr.  W.  requested  leave  to  examine  it :  and  when  the  stocking 
was  removed,  perceived  a  cicatrice  of  considerable  extent,  and  that 
the  tibia  was  much  enlarged.  The  patient  did  not,  however,  feel 
any  pain  in  this  bone.  He  expressed  in  writing  with  his  left  hand, 
that  several  years  before,  he  had  received  a  severe  blow  on  this  leg, 
and  that  a  large  piece  of  bone  had  come  away ;  he  could  not  recol- 
lect whether  he  took  any  mercury  at  that  time,  and  he  did  not 
think  that  his  surgeon  considered  the  disease  in  the  bone  as  vene- 
real. He  did  not  remember  having  had,  at  any  time,  spots  on  his 
skin  or  a  sore  throat.  His  present  ailment,  he  said,  had  never 
been  considered,  by  any  of  the  medical  persons  whom  he  had  con- 
sulted, as  venereal,  nor  had  the  use  of  mercury  ever  been  proposed 
for  its  cure. 

On  examining  his  neck,  Mr,  W.  found  several  of  the  vertebrae 
much  enlarged.  He  discovered  also  a  large  swelling  in  the  acro- 
mion of  the  right  scapula,  and  a  considerable  enlargement  of  the 
whole  of  the  spine,  and  greater  part  of  the  superior  costa,  of  that 
bone.  As  the  muscles  were  wasted,  a  swelling  was  readily  per- 
ceived in  the  os  brachii,  a  little  above  the  attachment  of  the  deltoid 
muscle.  The  right  clavicle  possessed  at  least  three  times  its  usual 
thickness. 

From  the  possibility  of  these  swellings  being  venereal,  Mr.  W. 
felt  justified  in  proposing  the  immediate  use  of  mercury.  The 
patient's  relations  were  apprehensive  that  his  extreme  weakness, 
and  the  apparently  rapid  approach  of  death,  would  render  the  ex- 
periment useless ;  but  willingly  consented  to  the  attempt  being 
made,  as  without  something  being  done,  and  done  quickly,  death 
seemed  inevitable. 

Accordingly,  one  drachm  of  the  strong  mercurial  ointment,  with 
five  grains  of  camphor,  was  rubbed  upon  his  skin  every  night,  and 
a  seton  was  inserted  in  the  back  of  his  neck.     In  four  days,  his 


692 

mouth  became  affected  from  the  mercury  ;  in  ten  days,  he  swal- 
lowed with  less  difficulty,  he  slept  well,  and  his  pains  were  nearly 
gone  in  a  fortnight,  the  enlargement  of  the  clavicle  was  evidently 
lessened,  and  his  muscles  were  much  fuller  and  firmer.  He  had 
also  recovered  his  speech,  so  far  as  to  make  himself  understood. 
The  quantity  of  the  ointment  was  now  increased  to  a  drachm 
night  and  morning,  and  the  use  of  it  was  continued  for  eleven 
weeks ;  towards  the  latter  part  of  v/hich  time,  when  he  could  swal- 
low with  ease,  he  took  about  eight  ounces  of  the  compound  decoc- 
tion of  sarsaparilla  daily,  and  now  and  then  some  preparation  of 
Peruvian  bark. 

During  this  course,  although  the  patient's  mouth  was  affected 
with  a  considerable  degree  of  soreness,  he  gathered  health  and 
strength  daily,  and  before  it  was  discontinued  had  grown  fat. 
His  muscles  had  acquired  very  nearly  their  original  plumpness 
and  strength,  and  the  limbs  their  former  capability  of  motion. 
The  pains  were  wholly  removed,  and  the  thickening  of  the  bones 
very  much  reduced.  His  power  of  swallowing  and  of  moving  the 
right  extremities,  seemed  at  first  to  increase,  in  the  same  propor- 
tion as  the  sweUings  of  the  cervical  vertebrae  decreased.  But  though 
these  swellings  afterwards  became  stationary,  the  powers  of  the 
muscles  were  completely  restored.  His  cure,  with  the  following 
exceptions,  was  perfect,  and  had  remained  so  for  more  than 
two  years.  The  pupil  of  the  left  eye  continued  more  dilated  than 
that  of  the  right,  and  the  eyelid  could  not  be  raised  quite  so  high  as 
formerly ;  but  he  could  distinguish  objects  and  colours  in  some 
measure  with  the  left  eye,  and  even  small  objects  when  he  used 
plain  green  spectacles,  and  employed  that  eye  only.  When  he 
used  both  eyes  his  vision  was  confused,  as  he  then  saw  objects 
double.  He  still  spoke  with  a  very  hoarse  voice,  but  his  articula- 
tion was  sufficiently  distinct.* 

XIV.     Amaurosis  from  Morbid  Changes  affecting  the  Fifth 
Pair  of  Nerves. 

When  disease  W'ithin  the  cranium  affects  principally  the  fifth 
pair  of  nerves,  a  train  of  symptoms  is  produced  similar  to  the 
changes  which  have  been  observed  to  follow  the  division  of  the 
trunk  of  the  nerve,  in  experiments  on  the  lower  animals.  Besides 
amaurosis,  more  or  less  complete,  there  is  inflammation  of  the  eye 
ending  in  ulceration  and  opacity  of  the  cornea,  insensibility  of  the 
conjunctiva  and  the  other  parts  supplied  with  common  sensation  by 
the  fifth  pair,  and  loss  of  taste  in  the  corresponding  side  of  the 
tongue.  Severe  neuralgia  generally  accompanies  this  amaurosis ; 
and  from  the  third  pair  being  often  involved  in  the  morbid  state  of  the 
brain  or  its  coverings,  the  muscles  of  the  eyeball  and  the  levator  of 
the  upper  eyelid,  are  apt  to  be  at  the  same  time  affected  with  par- 

*  Transactions  of  a  Society  for,the  Improvement  of  Medical  and  Chirurgical  Know- 
ledge, Vol.  iii.  p.  115.     London,  1812. 


693 

alysis.  These  various  symptoms  follow  each  other,  sometimes  in 
one  order,  sometimes  in  another.  In  some  cases  the  amaurosis,  in 
others  neuralgia,  is  the  complaint  which' attracts  the  most  attention  ; 
sometimes  the  disease  is  looked  upon  as  merely  an  obstinate  oph- 
thalmia, and  in  other  instances  it  is  considered  as  a  paralysis. 

Case.  A  young  man,  an  epileptic  in  the  hospital  La  Pitie, 
died  on  the  12th  of  August,  1824,  after  having  been  under  the  care 
of  M.  Serres,  for  ten  or  eleven  months.  When  he  was  admitted 
into  the  hospital,  he  complained,  in  addition  to  his  epileptic  seiz- 
ures, of  slight  inflammation  of  the  right  eye.  The  inflammation 
increased,  the  cornea  became  opaque,  and  sight,  at  first  disordered, 
was  ultimately  lost  by  this  cause.  The  organs  of  sense,  on  the 
right  side,  became  successively  deprived  of  their  natural  powers. 
This  took  place  in  June,  1824.  The  right  eye,  eyelids,  nostril, 
and  half  of  the  tongue,  were  deprived  of  sensation,  while  the  same 
parts  on  the  left  side  possessed  it  perfectly.  Shortly  after,  the  dis- 
ease was  aggravated  by  a  scorbutic  affection,  which  first  manifested 
itself  on  the  right  side  of  both  maxillae,  on  this  side  laying  the 
teeth  bare  by  an  affection  of  the  gums.  At  the  advanced  stage  of 
the  disease,  complete  deafness  took  place  on  the  right  side. 

On  dissection,  the  ganglion  of  the  fifth  pair  on  the  right  side 
was  found  to  be  swoln,  of  a  yellow  colour,  and  less  vascular  than 
usual ;  and  the  nerve,  where  it  seems  inserted  into  the  pons  Va- 
rolii, was  changed  into  a  yellow  gelatinous  substance,  like  the 
ganglion,  which  substance  transmitted  small  processes  into  the 
pons,  in  the  direction  of  the  fasciculi  of  the  insertion  of  the  nerve. 
The  muscular  branches  of  the  affected  nerve  were  unaltered,  and 
the  action  of  mastication  had  never  been  disturbed.* 

XV.     Amaurosis  from  Poisons. 

Almost  all  substances  included  under  the  classes  of  narcotic  and 
narcotico-acrid  poisons,  produce,  along  with  other  effects  on  the  ner- 
vous system,  dimness  of  sight  and  dilated  pupils.  Dilatation  and 
fixedness  of  the  pupils  follow  the  application  of  some  of  these  sub- 
stances even  to  the  skin  merely,  and  of  this  we  take  advantage  in 
the  treatment  of  several  of  the  diseases  of  the  eye  ;  but  it  does  not 
generally  happen,  that  belladonna,  or  hyosciamus,  the  substances 
usually  employed  in  this  way.  appear  to  cause  any  other  affection 
of  the  retina,  than  a  degree  of  obscurity  and  dazzling,  such  as  the 
mere  influx  of  light  through  a  much  dilated  pupil  might  induce. 
Taken  internally,  however,  these  poisons,  as  well  as  many  of  their 
congeners,  evidently  induce  insensibility,  more  or  less  complete,  of 
the  retina,  along  with  mydriasis  in  most  instances,  but  sometimes 
with  myosis.  They  also  cause  delirium,  coma,  convulsions,  and, 
if  not  speedily  counteracted,  death. 

The  effects  of  large  doses  of  belladonna  have  been  frequently 

*  SerreSj  Anatomic  Comparee  du  Cerveau,  Tome  ii.  p.  67.     Paris,  1827. 


694 

witnessed,  in  consequence  of  children  and  adults  being  tempted  to 
eat  the  berries  by  their  fine  colour  and  bright  lustre.  Dryness  of 
the  throat  is  an  almost  uniform  symptom  in  such  cases,  and,  along" 
with  difficulty  in  swallowing,  is  much  complained  of  by  the  pa- 
tient. The  delirium  is  generally  extravagant,  and  accompanied 
with  immoderate  and  uncontrollable  laughter,  sometimes  with  con- 
stant talking,  but  occasionally  with  complete  loss  of  voice.  The 
eyeballs  are  red  and  prominent.  Vision  is  more  or  less  affected  ; 
sometimes  so  much  so,  that  even  the  brightest  light  cannot  be  dis- 
tinguished. The  torpor  or  lethargy  which  follows  the  delirium, 
occurs  more  or  less  quickly,  but  in  general  not  for  several  hours 
after  the  poison  is  taken.  Convulsions  rarely  appear  to  be  produced 
by  belladonna.  The  effects  of  this  poison  are  by  no  means  so 
quickly  dissipated  as  those  of  opium.  The  blindness  especially,  is 
often  a  very  obstinate  symptom,  sometimes  remaining  long  after 
the  affection  of  the  mind  has  disappeared.  For  days,  and  even 
weeks,  the  pupils  may  continue  dilated,  and  vision  disordered. 

Similar  effects  are  produced  by  large  doses  of  hyosciamus,  or 
stramonium.  Blindness  with  dilated  pupils,  also  attend  poisoning 
by  white  hellebore,  tobacco,  and  several  other  substances.  Opium 
and  alcohol  also  induce  insensibility  of  the  retina,  sometimes  ac- 
companied with  dilatation,  but  more  frequently  with  contraction  of 
the  pupils. 

It  becomes  a  question  of  great  importance.  How  do  the  narcotic 
and  narcotico-acrid  poisons  act  in  the  production  of  amaurosis? 
Do  they  operate,  through  the  medium  of  the  nervous  system,  on 
that  part  of  the  brain  which  forms  the  immediate  organ  of  visual 
perception,  the  optic  nerve,  the  third  pair  which  animates  the  iris, 
and  the  other  nerves  connected  with  the  external  organs  of  this 
sense  ?  Or  do  they  merely  induce  congestion  of  the  vessels  of  the 
brain,  and  sometimes  extravasation  of  blood  within  the  liead  ? 
They  probably  act  in  both  these  ways.  Congestion  of  the  cere- 
bral vessels  is  commonly,  though  perhaps  not  invariably,  found 
on  dissection,  after  death  from  a  narcotic  or  narcotico-acrid  poison  ; 
and  must  undoubtedly  tend  to  produce  insensibility  in  cases  of  poi- 
soning, as  it  does  in  cases  of  apoplexy  or  cerebral  plethora.  But 
that  the  amaurotic  effects  of  the  poisonous  substances  in  question 
are  to  be  ascribed  wholly  to  congestion  does  not  appear  probable, 
v/hen  we  take  into  account  the  dilatation  of  the  pupils,  which, 
often  in  the  course  of  not  many  minutes,  follows  the  application 
of  belladonna  to  the  skin  of  the  eyelids,  and  which,  whether  it  is  to 
be  regarded  as  produced  by  nervous  communication  or  by  absorp- 
tion, can  scarcely  with  any  degree  of  plausibihty  be  supposed  to 
arise  from  cerebral  oppression. 

I  have  already  had  occasion  repeatedly  to  hint  my  suspicion,  that 
one  of  the  narcotico-acrids,  which  custom  has  foolishly  introduced 
into  common  use,  namely  tobacco,  is  a  frequent  cause  of  amaurosis. 
A  great  majority  of  the  amaurotic  patients,  by  whom  I  have  been 


695 

consulted  during  the  last  twelve  years,  have  been  in  the  habit  of 
chewing,  and  still  oftener  of  smoking,  tobacco,  in  large  quantities. 
It  is  difficult,  of  course,  to  prove  that  blindness  is  owing  to  any  one 
particular  cause,  when  perhaps  several  causes,  favourable  to  its  pro- 
duction, have  for  a  length  of  time  been  acting  on  the  individual ; 
and  it  is  especially  difficult,  to  trace  the  operation  of  a  poison,  daily 
applied  to  the  body,  for  years,  in  such  quantities  as  to  produce,  at  a 
time,  only  a  very  small  amount  of  deleterious  influence,  the  accumu- 
lative effect  being  at  last  merely  the  insensibiUty  of  a  certain  set  of 
nervous  organs.  At  the  same  time,  we  are  familiar  with  the  conse- 
quences of  minute  portions  of  other  poisons,  which  are  permitted  to 
operate  for  a  length  of  time  on  the  constitution,  such  as  alcohol, 
opium,  lead,  arsenic,  mercury,  &.c.,  and  we  can  scarcely  doubt,  that 
a  poison  so  deleterious  as  tobacco,  must  also  produce  its  own  pecu- 
liar injurious  effects. 

It  would  appear  that  there  are  two  principles  of  activity  in  tobac- 
co, an  essential  oil,  and  a  peculiar  proximate  principle  called  nico- 
tin,  both  of  which  are  capable  of  producing  death,  but  by  very  dif- 
ferent physiological  actions,  the  former  by  its  effects  on  the  brain, 
the  latter  by  its  influence  on  the  heart.  The  essential  oil  is  so  vir- 
ulent a  poison,  that  small  animals  are  almost  instantly  killed,  when 
wounded  by  a  needle  dipped  in  it,  or  when  a  few  drops  of'it  are  let 
fall  upon  their  tongue.  Dr.  Paris*  records  the  case  of  a  child,  whose 
death  was  occasioned  by  her  having  swallowed  a  portion  of  half- 
smoked  tobacco,  which  was  taken  from  the  pipe  of  her  father,  and 
in  which  there  no  doubt  existed  a  quantity  of  essential  oil,  which 
had  been  separated  by  the  act  of  smoking  ;  for  in  the  process  of 
smoking,  the  oil  is  separated,  and  being  rendered  empyreumatic 
by  heat,  is  thus  applied  to  the  fauces  in  its  most  active  state.  Now, 
that  the  regular  application,  in  this  way,  of  a  poison  of  such  power, 
perhaps  five  or  six  times  daily  for  months  or  years  together,  should 
at  length  be  productive  of  serious  effects  on  the  nervous  system,  and 
especially  on  the  brain,  cannot  surely  be  matter  of  wonder.  Indeed 
it  would  be  surprising,  if  it  were  otherwise. 

The  Germans  accuse  a  variety  of  bittet  substances,  employed 
either  for  food  or  medicine,  as  productive  of  amaurosis ;  but  with 
what  degree  of  justice,  I  cannot  pretend  to  say.  Beer  enumerates 
bitter  almonds,  the  root  of  succory,  quassia,  and  centaurium,  amongst 
this  class. 

Treatment.  1.  If  amaurosis  be  the  consequence  of  a  large  dose 
of  a  narcotic,  which  still  remains  in  the  stomach,  we  ought  in  gen- 
eral to  begin  by  giving  a  dose  of  tartar  emetic,  or  sulphate  of  zinc, 
in  as  small  a  quantity  of  water  as  possible;  for,  as  long  as  the  nar- 
cotic remains  in  the  stomach,  the  addition  of  any  fluid  which  would 
not  immediately  be  rendered  by  vomiting,  would  only  dissolve  the 
narcotic,  if  it  has  been  swallowed  in  the  solid  state,  and  add  to  its 

*  Pharmacologia,  Vol.  ii.  p.  451.    London,  1825. 


696 

activity.  Vinegar,  especially,  which  has  been  found  so  useful  io 
removing  the  disease  which  arises  from  opium,  only  adds  to  its  ac- 
tivity, if  it  be  given  before  the  poison  has  been  rendered  from  the  sto- 
mach. When  no  danger,  however,  of  this  kind  is  to  be  apprehend- 
ed, as  is  the  case  in  alcoholic  poisoning,  injections  into  the  stomach  by 
means  of  the  stomach  pnmp,  and  the  immediate  withdrawal  of  the 
fluid  injected,  along  with  the  poisonous  substance,  are  to  be  prefer- 
red. As^soon  after  the  contents  of  the  stomach  have  been  evacuated 
as  is  proper,  a  strong  purgative  ought  to  be  administered,  especially 
if  we  suspect  that  the  narcotic  has  began  to  traverse  the  intestines. 

2.  Bloodletting,  both  general  and  local,  is  of  great  use  in  cases 
of  amaurosis  from  narcotic  poisons.  This  remedy  probably  proves 
serviceable,  chiefly  by  relieving  the  tendency  to  cerebral  congestion^ 
which  uniformly  accompanies  this  amaurosis. 

3.  The  disease  produced  by  the  narcotic,  and  of  which  the  am- 
aurosis is  a  part,  ought  next  to  be  combated  hy  strong  doses  of 
coffee,  camphor,  vinegar,  and  the  vegetable  acids. 

4.  Cold  applications  to  the  head  and  eyes  have  been  found  use- 
ful. 

5.  In  inveterate  cases,  after  premising  blood-letting  and  purg- 
ing, a  course  of  mercury  may  be  tried,  with  counter-irritation  of 
different  sorts,  sternutatories,  and  electricity.  The  prognosis,  in 
this  stage,  is  very  unfavourable,  especially  if  the  pupils  are  fixed, 
the  retinae  insensible,  and  the  external  vessels  of  the  e3^e  varicose. 

Case.  On  May  24,  1815,  Mr.  J.  H.,  aged  19,  unaccustomed, 
except  for  a  day  or  two  before,  to  the  effects  of  tobacco,  smoked 
one,  and  part  of  a  second  pipe,  without  employing  the  usual  cau- 
tion of  spitting  out  the  saliva  ;  and  partook,  at  the  same  lime,  of  a 
little  porter.  He  became  affected  by  syncope,  with  violent  retch- 
ing and  vomiting.  He  returned  home,  complained  of  pain  in  the 
head,  undressed  himself,  and  went  to  bed.  Soon  afterwards  he 
was  taken  with  stupor  and  laborious  breathing. 

He  was  found  in  this  state  by  the  medical  attendant.  The 
countenance  was  suff'used  with  a  deep  livid  colour ;  the  eyes  had 
lost  their  brilliancy  ;  the  conjunctivae  were  injected  ;  the  right  pupil 
was  exceedingly  contracted  ;  the  left  was  much  larger  than  usual, 
and  had  lost  its  circular  form  ;  both  were  unaffected  on  the  approach 
of  light.  The  hands  were  joined,  and  in  a  state  of  rigid  contrac- 
tion ;  the  arms  bound  over  the  chest  ;  and  the  whole  body  affected 
with  spasmodic  contraction.  The  breathing  was  stertorous  ;  pulse 
about  80  or  82,  and  nearly  natuial  in  other  respects.  No  more 
vomiting  ;  no  stool  or  urine  passed  ;  no  palsy. 

Fourteen  ounces  of  blood  were  immediately  taken  from  the 
temporal  artery,  and  vinegar  was  administered.  He  revived  evi- 
dently ;  the  countenance  became  less  livid  ;  the  spasmodic  affection 
of  the  hands  ceased  ;  respiration  became  less  stertorous.  An  ipe- 
cacaunha  emetic  was  given,  and  operated  once,  and  afterwards 
some  purgative  medicine  was  administered. 


697 

He  dozed  through  the  night.  Next  morning  he  was  affected 
with  syncope,  during  the  efforts  made  to  get  out  of  bed  to  go  to 
stool.  He  complained  very  much  of  pain  of  the  head  and  eyes ; 
the  eyes  and  eyelids  appeared  red  and  suffused.  Tongue  loaded 
and  brownish.  One  stool.  Pulse  80  and  natural.  Continued  to 
doze.  The  feet  were  cold  in  the  morning.  Sixteen  ounces  of 
blood  were  taken  from  the  arm. 

On  the  third  day,  he  still  dozed,  and  complained  of  pain  in  the 
head,  nausea,  and  a  tendency  to  faint.  Countenance  more  natu- 
ral ;  pupils  natural,  and  contract  on  exposure  to  light.  Pulse  72. 
A  loose  stool  passed  insensibly  in  bed.  In  the  evening,  he  again 
became  affected  with  a  degree  of  stupor,  spasms  of  the  hands, 
and  stertor  in  breathing.  Six  ounces  of  blood  were  drawn  from 
the  temporal  artery,  vinegar  was  given,  a  bUster  applied  to  the 
forehead,  and  mustard  cataplasms  to  the  feet,  with  much  relief 
to  the  symptoms. 

On  the  fourth  day,  he  appeared  much  as  on  the  preceding 
morning.  There  was  some  pain  of  head,  but  no  sickness  or  vom- 
iting.    After  this  he  gradually  recovered.* 

XVI.  Amaurosis  from  Tnanition  or  Debility. 

This  species  of  amaurosis  declares  itself  from  its  commencement 
by  the  sensation  of  a  network  before  the  eyes,  seldom,  if  ever,  at- 
tended, however,  by  that  glittering  or  dazzhng  which  accom- 
panies the  same  symptom  in  some  other  varieties  of  the  disease. 
During  its  progress  the  power  of  vision  manifests  remarkable 
differences  in  degree,  according  to  the  physical  and  moral  influences 
which  affect  the  individual.  After  a  hearty  meal,  or  a  few  glasses 
of  wine,  or  during  the  influence  of  some  unexpected  elation  of 
mind,  the  patient  sees  for  a  short  time  much  better  than  he  did 
before ;  while  an  opposite  effect  is  produced  by  the  depressing  pas- 
sions, want  of  food,  conthmed  watching,  and  the  like.  Not  un- 
frequently,  this  amaurosis  first  declares  itself  by  the  sensation  of  a 
mist  before  the  eyes  in  the  evenings,  the  common  artificial  light 
being  too  weak  to  affect  sufficiently  the  diminished  sensibility  of 
the  nervous  apparatus  of  vision.  In  general  there  is  no  complaint 
of  pain,  neither  in  the  head  nor  in  the  eyes,  nor  any  feeling  of  ful- 
ness or  weight.  There  are  rarely  any  objective  symptoms,  except 
perhaps  dilated  pupils,  attended  by  evident  general  debility,  pale- 
ness, emaciation,  and  a  weak,  small,  and  frequent  pulse. 

Causes.  Among  the  most  frequent  causes  of  this  amaurosis 
may  be  mentioned  any  considerable  and  continued  loss  of  the 
fluids  of  the  body,  as  in  haemorrhage,  chronic  diarrhoea,  ptyalism, 
immoderate  venery,  onanism,  protracted  suckling,  the  abuse  of  re- 
ducing remedies,  and  the  like.  This  amaurosis  is  occasionally 
a  sequela  of  typhus  fever,  especially  when  this  disease  has  been 

*  Case  of  the  Effects  of  Tobacco,  by  Marshall  Hall,  M.  D.  in  the  Edin.  Medical 
and  Surgical  Journal,  Vol,  xii.  p.  11.    Edin.  1816. 


698 

attended  by  profuse  epistaxis,  or  treated  with  remedies  producing 
hyper-catharsis. 

It  has  ah-eady  been  mentioned,  that  plethoric  persons  are  in  gen- 
eral able  to  produce  a  degree  of  congestive  amaurosis  at  will,  by 
stooping,  tying  their  neckcloth  tight,  and  the  like.  We  also  fre- 
quently witness  a  temporary  amaurosis  from  exhaustion.  For  in- 
stance, if  the  nervous  system  is  the  seat  of  no  particular  excitement 
at  the  time,  we  ob-serve  that  by  the  sudden  abstraction  of  blood,  the 
organs  of  vision,  and  indeed  all  the  organs  of  sense,  are  strikingly 
enfeebled.  In  some  individuals  the  debility  continues  for  several 
days,  and  if  any  one  of  the  organs  of  sense  has  been  previously 
weaker  than  the  rest,  the  feebleness  of  that  organ  is  in  general  in- 
creased by  bloodletting.  When  syncope  is  produced  Ijy  loss  of 
blood,  sight  appears  to  be  the  sense  which  fails  first,  and  which  re- 
covers last.  Hearing  is  next ;  while  smell,  taste,  and  touch,  are 
less  affected,  and  more  easily  reanimated  by  excitation.  They  re- 
turn in  a  very  short  time  to  their  natural  state  ;  but  it  is  not  so  with 
sight.  It  is  a  popular  opinion,  that  blood-letting  weakens  thesight^ 
and  to  a  certain  length  the  opinion  is  founded  on  fact. 

Treatment.  The  object  of  the  treatment  is  by  diet  and  tonic 
remedies,  to  strengthen  the  digestive  organs,  remove  the  general 
debiUty  of  the  patient,  and  excite  the  sensibility  of  the  nervous  parts 
of  the  optic  apparatus.  Debilitating  discharges  are  to  be  restrained,, 
bad  practices  on  the  part  of  the  patient  avoided  ;  country  air,  mod- 
erate exercise,  the  cold  bath,  and  every  other  general  influence  likely 
to  restore  vigour,  are  to  be  employed. 

Local  stimulants,  such  as  etherial  vapours  directed  against  the 
eyes,  have  been  found  of  use  in  such  cases. 

Success  in  treating  this  disease  will  depend  much  on  the  practi- 
tionei-'s  discovering  the  particular  debilitating  cause  from  which  it 
has  originated  ;  and  when  the  disease  is  recent,  the  mere  avoidance 
of  the  cause  will  frequently  be  sufficient  to  arrest  its  progress. 

Case  1.  Arrachart  relates  the  case  of  a  young  man,  who  had  all 
his  life  been  accustomed  to  drink  wine  as  his  ordinary  beverage, 
but  who,  from  change  of  place,  was  obliged  to  drink  -a'ater  only. 
DiarrhcEa  was  the  consequence.  This  continued  for  nine  months, 
when  the  patient  was  seized  with  fever  of  intermittent  character. 
For  this  he  was  bled  twice  at  the  arm,  and  from  that  moment  his 
sight  began  to  fail.  A  third  bleeding,  from  the  foot,  sensibly  in- 
creased the  weakness  of  sight,  and  immediately  after  a  fourth  bleed- 
ing, also  from  the  foot,  the  patient  became  altogether  bUnd.  Large 
blisters  were  apphed,  and  tartar  emetic  given,  first  of  all  as  a  vomit, 
and  then  as  an  alterativ^e,  during  more  than  a  month,  without  any 
success.  The  exhaustion  of  the  patient  rapidly  increased,  and  still 
the  tartar  emetic  was  repeatedly  employed.  When  Arrachart  was 
called  in,  he  prescribed  mild,  nourishing,  and  easily  digested  food, 
and  put  a  seton  into  the  neck.  The  patient's  strength  began  to  im- 
prove, but  his  vision  remaining  as  before,  he  still  continued  to  take 


699 

six  grain  doses  of  tartar  emetic,  without  Arrachart's  knowledge. 
These  produced  convulsions,  without  any  evacuation.  Arrachart 
having  discovered  this,  prescribed  some  anodyne  and  antispasmodic 
remedies,  and  recommenced  the  nourishing  plan  of  diet.  In  two 
months,  the  patient  began  to  see  a  Utile  with  the  left  eye,  and  dur- 
ing the  course  of  the  next  three  months  the  vision  of  that  eye  sensi- 
bly improved,  but  the  right  eye  remained  blind.* 

Case  2.  Mrs.  S.  when  in  her  30th  year,  was  brought  to  bed  ; 
and  being  a  woman  of  a  healthy  constitution,  chose  to  suckle  her 
child  herself.     This  she  did  for  some  time,  without  feeling  any  in- 
convenience from  it;  but,  having  continued  it  six  weeks,  her  strength 
began  to  fail,  and  continued  to  decline  daily,  till  she  became  incapa- 
ble even  of  moving  about  the  house,  without  experiencing  a  very 
painful  languor.     About  the  same  time  her  sight  also  was  affected  ; 
at  first  only  in  a  small  degree,  but  afterwards  so  considerably,  that 
the  full  glare  of  the  mid-day  sun  appeared  to  her  no  stronger  than 
the  light  of  the  moon.     At  this  period  of  her  disorder,  no  black 
specks  were  perceived  with  either  eye,  nor  did  objects  at  any  time 
appear  covered  with  a  mist  or  cloud.     She  was  affected  with  vio- 
lent pain  in  the  neck,  running  upwards  to  the  side  of  the  head  ; 
and,  on  this  account,  the  person  who  attended   her,  thought  proper 
to  take  four  ounces  of  blood,  by  cupping,  from  the  part  first  affected. 
After  this,  her  sight  was  worse  than  before,  and  it  was  not  long  be- 
fore she  entirely  lost  the  use  of  both  eyes.     She  had  been  three  days 
in  this  state  of  blindness,  when  Mr.  Wathen  was  first  desired  to  see 
her.     He  found  both  pupils  very  much  dilated,  and  remaining  un- 
altered in  the  brightest  light.     His  first  advice  was,  that  the  child 
should  be  weaned  without  loss  of  time.     He  ordered,  at  the  same 
time,  bark  draughts   to  be  taken  by  the  mother  three  times  in  the 
day,  prescribing  also  an  opening  medicine  to  be  taken  occasionally, 
on  account  of  a  costive  habit  of  body,  to  which  she  had  been  almost 
constantly  subject  ever  since  the  time  of  her  deUvery.     To  the  use 
of  these  remedies  was  added  the  frequent  apphcation  of  the  vapour 
of  ether  to  the  eyes  and  forehead. 

On  the  fourth  day  after  this  mode  of  treatment  was  adopted,  Mr. 
Ware  visited  the  patient,  with  Mr.  Wathen,  From  the  account 
she  gave  of  herself,  her  strength  and  spirits  seemed  to  be  in  some 
degree  on  the  return  ;  and  she  could  now  perceive  faint  glimmerings 
of  fight,  though  the  pupils  of  both  eyes  were  in  the  same  dilated 
and  fixed  state  as  before.  The  bark  and  ether  were  continued, 
and  next  day  a  strong  stream  of  the  electric  fluid  was  poured  on 
the  eyes,  whilst  several  small  electric  sparks  were  variously  pointed 
about  the  forehead  and  temples.  The  day  after  this,  to  increase 
the  effect  of  the  electricity,  the  patient  was  placed  on  a  glass-footed 
stool,  and  the  same  experiments  repeated  as  before.  This  appeared 
to  have  a  considerable  influence  in  promoting  the  cure.     The  first 

*  Arrachart,  Memoires  de  Chirurgie^  p.  209-    Taris,  1805. 


700 

trial  was  almost  immediately  followed  by  such  a  degree  of  amend- 
ment, that  the  patient,  to  whose  sight  every  object  had  before  been 
confused,  could  now  clearly  distinguish  how  many  windows  there 
were  in  the  room  where  she  sat,  though  she  was  still  unable  to  make 
out  the  frames  of  any  of  them.  On  the  third  day,  soon  after  she 
had  been  thus  electrified,  the  menstrual  discharge  came  on  for  the 
first  time  since  she  had  been  brought  to  bed,  and  continued  three 
days,  during  which  it  was  thought  proper  to  suspend  the  use  both 
of  the  bark  and  the  electricity.  Immediately  after  this  they  were 
resumed  ;  and  the  effect  was  that  the  sight  mended  daily.  At  the 
end  of  a  week,  she  could  perceive  all  large  objects  ;  and  in  a  short 
time  she  could  read  even  the  smallest  print.  Her  strength,  indeed, 
did  not  return  so  quickly ;  on  which  account  she  was  advised  to 
remove  into  the  country,  where  the  change  of  air,  with  the  help  of 
a  mild  nutritious  diet,  soon  restored  her  to  perfect  health.* 

Case  3,  A  country  lad,  of  robust  constitution,  became  the  alter- 
nately favoured  paramour  of  two  females,  his  fellow-servants,  under 
the  same  roof.  He  was  the  subject  of  gutta  serena  in  less  than  a 
twelve-month.f 

Case  4.  Another,  at  an  early  period  of  puberty,  suddenly  fell 
into  despondency,  and  shunned  society.  He  never  left  his  chamber 
but  when  the  shade  of  night  concealed  him  from  observation,  and 
then  selected  an  unfrequented  path.  It  was  not  discovered  till  too 
late,  that  in  addition  to  other  signs  of  nervous  exhaustion,  a  palsy 
of  the  retina  was  the  consequence  of  habitual  masturbation. + 

XVII.     Amaurosis  from  Irritation  of  the  Branches  of  the  Fifth 

Pair  of  Nerves. 

This  appears  to  be  by  no  means  an  unfrequent  cause  of  sympa- 
thetic amaurosis ;  numerous  instances  being  on  record,  in  which 
the  removal  of  tumours  in  contact  with  branches  of  the  fifth  pair, 
and  of  carious  teeth,  has  been  the  means  of  suddenly  restoring 
sight. 

Case  1.  The  daughter  of  a  person  belonging  to  the  establish- 
ment of  the  Marquis  of  Buckingham,  at  Stow,  about  12  years  of 
age,  was  brought  to  Mr.  Ware,  on  account  of  total  bUndness  of  the 
left  eye,  which  had  continued  for  six  months  without  any  visible 
cause  to  produce  it. 

Upon  the  removal  of  a  small  encysted  wart,  which  was  situated 
on  the  edge  of  the  lower  eyelid,  very  near  the  punctum  lachrymale, 
the  child  surprised  Mr.  "W.  by  immediately  saying  that  she  had  re- 
covered her  sight,  and  by  telling  him  the  name  of  everything  that 
was  held  up  before  her.§ 

Case  2.     A.  healthy  middle-aged  man,  a  ship-painter  by  trade, 

*  Ware's  Observations  on  the  Cataract  and  Gutta  Serena,  p-  385.    London,  1812. 
t  Travers'  Synopsis  of  the  Diseases  of  the  Eye,  p.  145.     London.  1820. 
X  Travers'  Synopsis  of  the  Diseases  oftheEye,  p.  145.     London,  1820. 
'  Observations  on  the  Cataract  and  Gutta  Serena,  p.  424.     Lond.  1812. 


701 

desired  Mr.  Howship's  advice  in  1808,  on  account  of  a  small 
tumour  situated  on  tlie  crown  of  the  head.  It  was  at  least  ten  years 
since  he  had  first  perceived  it.  He  supposed  it  might  have  been 
the  consequence  of  some  blow  on  the  part,  as  those  in  his  line  of 
business  were  very  subject  to  such  accidents.  It  had  never  been 
painful,  but  yet  he  thought  his  general  health  was  giving  way,  as  for 
some  years  he  had  been  subject  to  headach,  a  complaint  he  never 
was  afflicted  with  in  his  life  before.  The  frequency  of  the  headach 
was  increasing,  and  his  sight  had  become  so  weak,  that  for  more 
than  two  years  he  had  been  totally  unable  to  read  even  the  largest 
and  clearest  print.  On  pressure,  no  pain,  or  even  sense  of  feehng, 
was  excited  in  the  tumour  on  the  scalp. 

Having  frequently  removed  such  tumo^n's,  Mr.  Howship  advised 
extirpation,  which  was  done  accordingly,  by  carrying  two  elliptical 
incisions  through  the  teguments  beyond  the  basis  of  the  tumour, 
the  portion  of  included  scalp,  with  the  tumour  itself,  being  subse- 
quently dissected  away  from  the  pericranium,  with  which  it  was  in 
contact.  Two  small  vessels  w^ere  tied,  and  the  integuments  brought 
nearly  together,  with  adhesive  plaster.  In  three  weeks  the  hgatures 
were  off,  and  the  wound  perfectly  healed. 

On  examination,  the  tumour  proved  to  be  a  strong  cartilaginous 
cyst,  seated  in  the  cellular  membrane  beneath  the  scalp.  The 
cavity  of  the  cyst  was  filled  with  a  yellow  ])urulont  fluid  ;  the 
thick  parts  of  which  had  formed  a  curdy  deposit  upon  the  sides  of 
the  cavity. 

The  patient  had  not  lost  above  an  ounce  of  blood  in  the  opera- 
tion, but  he  rather  unexpectedly  felt  his  head  better  the  following 
evening,  than  for  many  months  before.  He  found  his  uneasiness 
and  pain  in  the  head  continue  to  diminish  from  day  to  day,  and 
stated,  with  some  degree  of  surprise,  that  he  also  found  his  sight 
becoming  much  stronger,  and  clearer  than  before.  By  the  time 
the  wound  was  healed,  he  had  quite  lost  all  remains  of  pain  in  his 
head,  and  his  sight  was  so  greatly  improved,  that  he  was  now 
again  able  to  read  the  same  small-printed  book  that  he  had  been 
in  the  habit  of  using  ten  years  before ;  nor  did  the  pains  in  the 
head,  or  the  affection  of  the  sight,  afterwards  return.* 

Case  3.  F.  Przesmycki,  aged  30,  who  had  always  enjoyed 
good  health,  with  the  exception  of  occasional  rheumatic  pains  in 
the  head  and  joints,  was  suddenly  seized  in  the  autumn  of  1825, 
with  violent  pain  shooting  from  the  left  temple  to  the  eye  and  side 
of  the  face.  This  pain  was  attributed  to  cold  ;  it  lasted  several 
days,  then  subsided,  but  returned  periodically  without  being  so  se- 
vere as  to  lead  him  to  consult  a  medical  man.  But  in  two  months 
it  recurred  with  such  intensity,  especially  in  the  eye,  that  that  or- 
gan appeared  to  the  patient  about  to  start  from  its  socket,  and  at 
the  same  time   he  became  sensible  of  having  lost  the  power  of 

*  Howship's  Practical  Observations  in  Surgery  and  Morbid  Anatomy,  p.  1. 
London,  1816. 


702 

vision  on  that  side.  This  discovery  induced  him  to  have  recourse 
to  professional  assistance,  and  for  six  months  various  plans  of 
treatment  were  adopted,  without  any  other  advantage  than  that 
the  pain  became  periodical  instead  of  continual.  At  the  expiration 
of  this  period,  the  pain  acquired  new  force,  the  cheek  became 
swollen,  and  during  the  night,  several  spoonfuls  of  bloody  pus 
were  discharged  from  between  the  conjunctiva  and  the  left  lower 
eyelid  ;  after  which  the  sweUing  subsided,  and  the  pain  diminished, 
but  the  blindness  remained  as  complete  as  before.  In  three  weeks 
a  similar  discharge  took  place,  and  during  the  next  six  months  it 
was  occasionally  repeated.  In  the  winter  of  1826,  the  disease  was 
so  severe,  that  at  the  commencement  of  1827,  the  patient  proceeded 
to  Wilna,  with  the  intention  of  having  the  eye  removed,  if  he 
should  find  no  other  means  of  relief. 

M.  Galenzowski;  who  was  now  consulted,  found  the  vision  of 
the  left  eye  lost,  the  pupil  remaining  dilated.  He  conceived  that 
pus  had  formed  in  the  maxillary  sinus,  and  made  its  way  along 
the  orbital  part  of  the  superior  maxillary  bone  :  but  knowing  also 
that  suppurations  of  the  upper  jaw  frequently  depend  upon  carious 
teeth,  a  careful  examination  was  made,  and  a  rotten  tooth  found 
corresponding  to  the  antrum.  This  tooth  was  extracted,  to  give  a 
new  outlet  to  the  purulent  matter,  and,  to  the  astonishment  of  M. 
Galenzowski  and  his  patient,  there  was  found  attached  to  its  root 
a  spUnter  of  wood,  about  three  lines  long,  and  as  thick  as  the  head 
of  a  pin.  The  splinter  is  supposed  to  have  been  originally  detached 
from  a  tooth-pick  of  wood,  as  no  other  probable  explanation  could 
be  given.  The  removal  of  a  probe,  introduced  into  the  antrum, 
was  followed  by  a  few  drops  of  sero-purulent  fluid,  and  in  nine 
days  afterwards  the  patient  completely  regained  his  sight.* 

XYIII.     Amauj'osis  from    Worms  i?i  the  Intestines. 

Among  the  symptoms  generally  enumerated  as  indicative  of 
the  presence  of  worms  in  the  bowels,  are  dilatation  of  the  pupil, 
want  of  lustre  in  the  eye,  blueness  round  the  lower  eyelid,  epipho- 
ra, paleness  of  the  countenance,  headach,  throbbing  in  the  ears, 
and  disturbed  sleep  ;  while,  in  certain  cases,  we  are  told  that  am- 
aurosis, deafness,  and  apopletic  or  epileptic  fits,  arise  from  the  same 
cause.  The  presence,  however,  even  of  the  majorit}^  of  these  signs 
cannot  be  regarded  as  conclusive  evidence  of  the  existence  of 
worms,  nor  indeed  any  other  signs  whatever,  except  their  actual 
detection  in  the  alvine  excretions,  or  in  the  matter  vomited  by  the 
patient.  It  must  also  alwa3'S  admit  of  doubt,  whether  the  amauro- 
tic symptoms  present  in  those  who  are  troubled  with  worms,  do 
not  spring  from  some  other  cause,  as  hydrocephalus  or  some  mor- 
bid formation  within  the  cranium.  One  of  my  medical  friends  in- 
forms me,  that  he  some  time  ago  treated  a  child,   who  was  amau- 

*  Archives  Generales  de  Medecine,  Tome  xxiii.  p.  261.     Paris,  1830. 


703 

lotic,  and  who  at  the  same  time  passed  numerous  lumbiici,  to 
which  he  was  led  to  attribute  the  affection  of  the  eyes.  The  am- 
aurosis, however,  did  not  yield  to  anthelmintic  remedies,  the  child 
died,  and  on  dissection,  the  pituitar}^  gland  was  found  dilated  into 
a  cyst,  which  pressed  upon  the  optic  nerves,  and  had  caused  the 
absorption  of  their  medullary  substance. 

XIX.  Atnaur 0 sis  f 7^0171  Acute  or  Chronic  Disorders  of  the  Di- 
gestive Orgatis. 

Every  person,  liable  to  occasional  fits  of  dyspepsia,  makes  men- 
tion of  certain  symptoms  affecting  the  organs  of  vision,  as  distension 
and  stiff"ness  of  the  eyeballs,  dazzling  and  mistiness  before  the  eyes, 
muscse  volitantes,  and  the  hke.  These  symptoms  are  generally  at- 
tended by  headach,  and  sometimes  by  vertigo,  and  gradually  sub- 
side as  the  stomach  recovers  its  wonted  activity.  In  some  cases, 
however,  the  sympathetic  effects  of  indigestion  are  more  alarming, 
consisting  in  dilatation  of  the  pupils,  sluggishness  in  the  n^otions  of 
the  iris,  and  a  great  degree  of  dimness  of  sight.  The  patient  com- 
plains, at  the  same  time,  of  constant  acid  or  foul  eructations,  with 
painful  heartburn,  a  feeling  of  pressure  at  the  scrobiculus  cordis, 
distention  of  the  abdomen,  a  great  degree  of  flatulence,  thirst,  nau- 
sea, general  uneasiness  and  restlessness ;  the  mouth  is  bitter,  the 
tongue  foul,  and  the  pulse  accelerated. 

All  these  symptoms,  including,  among  the  rest,  the  amaurotic, 
speedily  subside  in  general,  after  the  use  of  some  absorbent  and 
laxative  medicine,  as  magnesia  usta,  or  the  carbonate  of  magnesia, 
a  mixture  of  these  with  rhubarb  and  ginger,  or  the  like. 

Frequently  repeated  and  neglected  attacks,  however,  of  this  kind, 
especially  in  sedentary  persons,  careless  perhaps  of  their  diet,  and 
inattentive  to  the  means  of  preserving  health,  lead  at  last  to  more 
serious  consequences.  The  bowels  grow  habitually  inactive,  the 
biliary  organs  aie  impeded  in  the  discharge  of  their  office,  the  ap- 
petite is  impaired,  digestion  weakened,  the  mind  becomes  habitually 
fretful,  and  the  spirits  depressed.  Undor  such  circumstances,  allow- 
ed to  continue  uninterruptedly  for  years,  there  is  not  unfrequently 
produced  a  slowly  increasing  weakness  of  sight,  terminating  at  last 
in  confirmed  amaurosis.  In  Milton,  whose  case  I  apprehend  to 
have  been  one  of  this  sort,  the  affection  of  vision  went  on  for  ten 
years  before  it  ended  in  blindness  ;  and  it  sometimes  happens,  that 
even  a  longer  period  elapses,  before  the  disease  is  fully  developed. 
The  patient,  during  all  this  time,  complains  of  a  constantly  increas- 
ing imperfection  of  sight,  without  being  rendered  unable,  perhaps, 
to  continue  his  usual  employments.  Though  generally  slow  in  its 
progress,  yet  there  sometimes  occur  cases,  in  which  this  species  of 
amaurosis  is  rapid,  or  even  metastatic. 

The  pupil  is  dilated,  the  motions  of  the  iris  very  sluggish  and 
limited,  the  sclerotica  tinged  of  a  yellowish  or  dusky  hue,  the  vessels 
of  the  conjunctiva  often  turgescent.     Every  object  seems  to  the  pa- 


704 

tient  enveloped  in  a  thick  cloud,  and  not  unfrequently  he  sees  only 
parts  of  the  objects  at  which  he  is  looking.  Dull,  stupifying  head- 
ach  generally  accompanies  the  failure  of  sight,  extending  over  the 
whole  head,  and  depriving  the  patient,  even  when  a  considerable 
share  of  vision  remains,  of  all  pleasure  in  those  employments  which 
require  the  exercise  at  once  of  sight  and  thought. 

Treatment.  A  relinquishment  of  whatever  appears  to  have  laid 
the  foundation  of  the  affection  of  the  digestive  organs  is  the  most 
important  particular  in  the  treatment  of  this  amaurosis ;  whether 
the  cause  has  been  severe  and  protracted  study,  irregularities  in  diet, 
the  use  of  alcoholic  and  other  poisons,  want  of  exercise,  impure  air, 
or  the  like.  The  patient's  food  should  be  plain  and  easily  digested,- 
he  must  pay  particular  attention  to  keep  his  bowels  regular,  he 
ought  to  take  daily  exercise  in  the  country  on  foot  or  on  horseback, 
and  court  the  society  of  the  cheerful  and  well-informed.  Alterative 
doses  of  mercury  will  often  be  useful,  and  much  advantage  will  be 
reaped  from  the  use  of  tonic  medicines,  judiciously  selected  and 
combirred. 

Beer  strongly  dissuades  from  the  use  of  emetics  and  nauseating 
medicines  in  the  treatment  of  amaurosis  depending  on  chronic  dis- 
order of  the  digestive  organs  ;  also,  from  all  external  stimulants,  and 
from  electricity  or  galvanism. 

Case  1.  Scarpa  relates  the  case  of  a  girl,  aged  sixteen  years,  of 
delicate  constitution,  and  who  had  not  menstruated,  who  towards 
the  end  of  May,  became  affected  with  such  a  degree  of  morbid  ap- 
petite, that  she  could  scarcely  satisfy  it  by  swallowing  every  sort  of 
gross  food  in  large  quantity,  especially  bread  made  of  Indian  corn. 
Fatigued  also  by  the  hard  labour  of  the  country,  to  which  she  was 
not  yet  accustomed,  her  sight  began  to  grow  dim.  Her  immoderate 
appetite  suddenly  ceased,  she  felt  a  bitter  taste  in  her  mouth,  and 
began  to  experience  a  sense  of  weight  in  the  region  of  the  stomach, 
accompanied  by  nausea  and  continual  headach.  She  then  lost  the 
sight  of  the  right  eye  entirely,  and  hn  a  great  measure  that  of 
the  left.  The  pupils  were  considerably  dilated,  and  almost  immov- 
able to  the  strongest  light.  She  seemed  also,  as  if  she  had  an  inci- 
pient strabismus. 

On  the  4th  of  June,  she  took  in  tablespoonfuk,  a  solution  of  four 
grains  of  tartar  emetic  in  five  ounces  of  water,  which  produced  a 
great  and  continued  degree  of  nausea,  but  no  vomiting,  except  of  a 
little  viscid  whitish  matter.  On  the  fifth,  the  same  emetic  was 
repeated  in  the  same  manner.  It  produced  a  more  copious  vomiting 
than  on  the  preceding  day ;  but  always  of  mucous  whitish  matter. 
The  headach,  however,  was  considerably  relieved,  as  well  as  the 
sense  of  weight  in  the  region  of  the  stomach.  The  nausea,  how- 
ever, and  furred  tongue,  continued  as  at  first.  The  pupil  appeared 
a  little  moveable  to  a  bright  light,  and  with  the  right  eye  the  patient 
could  distinguish  whether  it  was  light  or  dark.  She  began  to  ex- 
pose the  eyes  to  the  vapour  of  ammonia  every  two  or  three  hours. 


705 

On  the  6th,  she  had  httle  pain  in  the  head,  and  the  mouth  was 
less  bitter.  Tlie  pupil  had  acquired  some  degree  of  motion.  She 
was  ordered  to  take  three  resolvent  powders*  daily,  and  to  continue 
the  ammoniacal  vapour.  On  the  seventh  she  had  a  very  little  head- 
ach.  The  powders  had  produced  nausea  for  some  hours,  then  two 
copious  stools.  The  pupil  contracted  a  httle,  and  the  patient  could 
discern  the  outlines  of  large  objects.  By  the  8th,  the  headach  was 
entirely  gone,  as  well  as  the  bitter  taste  and  furred  state  of  the 
tongue.  The  pupil  also  was  more  sensible.  The  patient  con- 
tinued to  take  the  resolvent  powders  on  the  9th,  10th,  11th,  and 
12th,  and  to  use  the  ammonia.  On  the  13th,  she  complained 
again  of  headach,  and  bitterness  of  the  mouth,  with  foul  tongue. 
Instead  of  the  powders,  Scarpa  prescribed  an  emetic  of  half  a  drachm 
of  ipecacuanha  with  a  grain  of  tartar  emetic,  in  consequence  of 
which  the  patient  vomited  much  yellowish-green  matter.  The 
headach  ceased  immediately,  and  the  girl  could  then  distinguish 
sufficiently  well  the  objects  that  were  presented  to  her.  On  the 
18th,  she  felt  herself  very  well.  The  pupil  of  the  right  eye,  which 
had  been  the  most  amaurotic,  was  even  more  contracted  than  that 
of  the  left.  On  the  15th,  the  patient  resumed  the  use  of  the  resolv- 
ent powders,  and  continued  the  external  application  of  the  ammon- 
ical  vapour.  On  the  16th.  she  could  distinguish  with  the  right  eye 
a  small  needle.  During  the  17th,  18th,  19th,  and  20th,  the  pow- 
ders produced  two  copious  stools  daily,  without  at  all  weakening  the 
patient.  She  had  a  good  appetite,  and  digested  well.  On  the  21st, 
a  decoction  of  cinchona,  with  infusion  of  valerian  root,  was  substi- 
tuted for  the  resolvent  powders.  She  was  able  in  a  few  days  to  see 
the  most  minute  objects,  as  well  with  the  one  eye  as  the  other. 
She  had  acquired  a  good  complexion,  and  the  strabismus  had  almost 
entirely  disappeared.  She  was  dismissed  perfectly  cured,  but  ad- 
vised to  continue  the  use  of  the  vapour  for  a  week  longer,  to  take 
morning  and  evening  a  powder,  composed  of  one  drachm  of  cin- 
chona, and  half  a  drachm  of  valerian,  to  observe  a  regular  diet,  and 
to  avoid  the  scorching  rays  of  the  sun.t 

Case  2.  Ehzabeth  Healey,  a  slender  delicate  young  woman, 
about  25,  of  a  sedentary  occupation,  an  emaciated  figure,  and  feeble 
melancholic  temperament,  applied  to  Mr.  Lessey  on  the  9th  of  June, 
1820,  for  relief  of  an  affection  of  the  bowels,  to  which  she  had  been 
liable  for  several  years,  requiring,  even  in  a  state  of  comparative 
convalesence,  the  constant  use  of  purgatives.  Indeed,  the  derange- 
ment of  the  abdominal  viscera  was  so  great  and  permanent,  as  to 
induce  a  belief  that  it  was  of  an  organic  nature.  In  addition,  she  was 
liable  to  frequent  and  severe  cephalalgia,  and  occasionally  to  attacks 
of  dyspnoea,  with  spasms  of  the  chest  and  throat,  which,  on  her 
attempting  to  swallow,  produced  alarming  symptoms  of  suffocation. 
These  attacks  were  sudden  and  violent,  were  attended  by  great 

*  See  page  652. 

t  Trattato  delle  principali  Mallattie  degli  Occhi.    Vol.  ii,  p.  281.     Pa\ia,  1816. 

89 


706 

feebleness  of  the  voice,  and  succeeded  by  exhaustion.     Her  bowels: 
had  been  frequently  relieved  by  mercurial  and  saline  cathartics, 
the  attacks  of  cephalalgia  by  venesection,  and  the  application  of 
leeches  and  blisters  to  the  head  and  neck,  and  the  affection  of  the 
lungs  by  a  variety  of  remedies. 

She  had  an  attack  of  disordered  bowels  in  January,  1821,  which 
appeared  to  be  yielding  to  remedies,  when  she  was  suddenly  seized, 
on  the  23d,  with  violent  dyspnoea.  Every  attempt  to  swallow,  or 
even  to  speak,  was  followed  by  a  convulsive  spasm  of  the  throat 
and  chest,  attended  with  frequent  sobbing.*  A  few  doses  of  ether 
and  opium,  with  a  blister  on  the  sternum,  relieved  the  immediate 
urgency  of  the  symptoms  ;  but  still  the  breathing  continued  labori- 
ous, and  the  voice,  which  had  long  been  feeble,  was  reduced  to  a 
scarcely  audible  whisper.  The  derangement  of  her  abdominal 
viscera  returned  ;  her  stools  were  green  and  slimy  ;  her  pulse  was 
feeble  and  her  general  debility  so  great,  that  Mr,  Lessey  despaired  of 
her  recovery. 

She  remained  in  this  state,  with  little  variation,  till  the  15th  of 
February,  when  the  difficulty  of  breathing  suddenly  left  her,  and  her 
voice  became  distinct,  strong,  and  clear  ;  but  a  sudden  and  violent 
pain  seized  her  head,  and,  to  the  astonishment  of  the  people  around 
her,  she  screamed  out  loudlj^  for  help.  Hastening  to  her  assistance, 
the}^  found  her  in  an  agony  of  pain,  and  quite  blind.  Mr.  Lessey 
immediately  ordered  her  head  to  be  shaved,  and  a  bhster  applied  to 
it,  with  a  dozen  of  leeches  to  the  temples,  which  abated  the  violence 
of  the  pain,  but  produced  no  alteration  in  her  sight.  The  eyes  were 
fixed,  and  nearly  motionless  ;  the  pupil  steady  at  a  medium  point, 
between  contraction  and  dilatation,  and  totally  insensible  to  hght. 
On  presenting  a  candle  suddenly  to  her  eyes,  she  exhibited  no  con- 
sciousness of  its  presence,  unless  it  was  sufficiently  near  for  her  to 
feel  the  the  warmth  of  its  rays.  Blisters  were  applied  to  her  temples, 
dressed  with  cantharides  ointment,  and  frequently  repeated,  so  as 
to  keep  up  a  discharge  for  weeks.  The  bowels  continued  torpid, 
and  required  the  constant  use  of  purgatives.  Blue  pill  was  next 
tried,  and  her  gums  were  slightly  affected,  but  without  any  effect 
on  her  sight.  Her  voice  continued  strong,  her  breathing  easy,  and,, 
in  fact,  the  affection  of  the  chest  appeared  to  have  left  her  entirely. 

The  pain  in  the  head  was  considerably  abated,    but  the  vision 
remained  so  entirely  lost,  that  all  hopes  of  its  recovery  were  aban- 
doned, and  she  was  sent  to  the  Manchester  workhouse,  as  an  incur- 
able amaurotic. 

Three  months  after  her  admission,  she  had  a  severe  attack,  both 
in  her  chest  and  bowels,  obstinate  constipation,  dyspnoea,  with  violent 

*  Such  paroxysms,  as  are  here  described  by  Mr.  Lessey,  are  generally  regarded  as- 
hysterical.  In  a  female  subject,  who  had  long  been  subject  to  such  fits,  I  found,  on 
dissection,  the  heart  of  a  remarkably  small  size.  She  had  been  bled  exceedingly 
often  in  the  course  of  the  five  or  six  years  preceding  her  death,  and  perhaps  to  this 
circumstance  the  smallness  of  the  heart  might  be  owing. 


707 

spasm,  and  great  difficulty  of  swallowing.  This  attack  lasted  three 
weeks,  and  subsided  slowly.  At  the  latter  end  of  1822,  she  had  a 
slight  attack  of  pleurisy,  which  yielded  to  bleeding,  blistering,  and 
the  usual  treatment ;  after  which  she  remained  tolerably  free  from 
all  her  complaints,  excepting  slight  headachs. 

Although  she  entertained  little  or  no  hope  of  again  recovering 
her  sight,  yet  she  occasionally  tried  her  eyes  with  a  candle.  On 
the  evening  of  the  29th  of  October,  she  perceived  no  ghmmering 
whatever  ;  but,  to  her  great  surprise,  on  the  following  evening,  as 
a  person  was  conducting  her  through  the  streets,  she  saw  a  confused 
appearance  of  fire,  and  exclaimed,  What  is  the  matter  with  wiy 
eyes  7  In  the  course  of  a  few  minutes,  she  discovered  that  it  pro- 
ceeded from  the  gas  lamps,  which  she  saw  indistinctly.  Her  sight 
gradually  improved  during  the  course  of  the  evening.  Next  day 
Mr.  Lessey  found  that  there  was  considerable  mistiness  and  obscurity 
in  her  vision,  with  muscse  volitantes,  of  a  fiery  hue ;  but  that  she 
could  distinguish  the  featiu'es  of  her  acquaintances,  and  could  even 
read  the  large  capitals  of  a  hand-bill,  the  smaller  print  seeming  con- 
fused, and  blended  together.  All  distant  objects  were  mixed  up 
with  coloured  mists,  and  consequently  indistinct  and  confused. 

On  the  20th  of  November,  her  sight  remained  much  the  same. 
It  had  got  better,  however,  during  the  interval,  but  was  injured 
again  by  injudicious  exposure  to  a  highly  heated  room.  The  col- 
oured mists  still  troubled  her  occasionally ;  the  muscse  volitantes 
were  sometimes  very  numerous,  and  appeared  mixed,  she  said,  with 
white  flakes  like  snow.  She  could  not  read  better  ;  but,  with  the 
help  of  a  double  concave  glass,  she  could  distinguish  print,  which, 
to  her  naked  eye,  was  a  confused  mass.  Her  bowels  and  lungs  had 
been  free  from  disease  for  twelve  months,  and  she  exulted  in  the 
prospect  of  ultimate  recovery.* 

Case  3.  Mr.  Samuel  Smith,  aged  52,  a  patient  of  Mr.  Gooke, 
had  enjoyed  a  remarkably  good  state  of  health,  with  the  exception 
of  an  occasional  attack  of  lumbago,  and,  during  two  years,  intima- 
tions of  dyspepsia.  The  remedies  employed  for  these  were  of  the 
mildest  character,  usually  affording  temporary  relief  Early  in 
1826,  he  became  the  subject  of  more  severe  indisposition,  the 
leading  features  of  which  were  derangements  in  the  digestive  organs, 
particularly  the  liver,  with  some  tenderness  in  the  region  of  that 
viscus.  This  state,  accompanied  with  pains,  affecting  the  head, 
jihoulders,  loins,  and  chest,  was  ascribed  to  exposure  to  cold,  after 
the  loss  of  a  considerable  quantity  of  blood  from  the  socket  of  a  loose 
tooth  removed  by  a  dentist.  After  an  attack  of  lumbago,  the  right 
temple  became  exceedingly  painful ;  the  left  temple  and  the  shoul- 
ders were  successively  affected,  and  ultimately  the  pectoral  muscle 
of  the  right  side,  and  the  flexor  muscles  of  the  arms.  The  patient 
described  the  pains  as  gnawing,  with  exacerbation  towards  night ; 

**  Edin.  Medical  and  Surgical  Journal.     Vol.  xxv.  p.  319.    Edin.  1826. 


708 

the  pain  of  the   head  being  seated  in  the  external  parts,  and 
not  attended  by  internal  throbbing  or  giddiness. 

Conjointly  with  attention  to  the  state  of  the  hepatic  secretion,  the 
application  of  leeches  to  the  right  hypochondrium,  and  a  moderate 
abstraction  of  blood  from  the  arm.  the  acetum  colchici  was  adminis- 
tered, and  fomentations,  as  well  as  solution  of  opium,  were  applied, 
during  the  more  distressing  paroxysms  of  pain,  to  the  head.  In 
little  more  than  a  fortnight  the  pain  ceased,  and  in  a  few  days 
more  he  ventured  into  business.  Still  the  progress  of  recovery  was 
very  slow  ;  his  appetite  remained  capricious,  his  bowels  irregular, 
his  sleep  was  interrupted,  he  had  tenderness  in  the  epigastrium, 
and  his  muscular  powers  v/ere  feeble. 

At  this  period,  he  observed  that  his  sight  was  not  quite  so  clear 
as  formerly  ;  for,  though  after  looking  towards  an  object  for  a  short 
time  he  could  see  it  distinctly,  yet  the  eyes  were  longer  in  adapting 
themselves  to  changes  of  hght  than  is  usually  the  case ;  and  he 
was  constantly  annoyed  by  muscse  volitantes  in  both  eyes.  These 
illusions  were  regarded  as  a  nervous  derangement,  and  the  patient 
was  led  to  hope  that  they  would  disappear  as  he  gained  strength. 
A  change  of  air  was  recommended,  and  he  went  to  Hastings  on 
the  23d  of  May.  During  his  stay  on  the  coast,  a  period  of  from 
five  to  six  weeks,  his  general  health  was  a  little  improved ;  but 
after  the  first  fortnight,  he  began  to  experience  a  violent  pulsation 
on  the  left  side  of  his  head. 

He  returned  to  Camberwell  the  2ist  or  22d  of  June,  much  the 
same  in  general  health,  and  with  no  improvement  in  his  eyes. 
Some  days  afterwards  he  found  the  right  eye  becoming  more  dim 
and  on  the  night  of  June  29th,  it  became  nearly  dark.  On  Satur- 
day the  30th,  Mr,  Cooke  was  requested  to  see  him.  There  was  no 
appearance  of  inflammation,  but  a  very  slight  opacity  of  the  pupil. 
He  complained  of  pain  and  pulsation  along  the  left  side  of  the  head, 
but  there  had  been  no  aggravation  of  this  affection  to  explain  the 
increased  dimness  in  the  opposite  eye.  The  abstraction  of  twelve 
ounces  of  blood,  by  cupping,  was  immediately  ordered ;  a  blister 
was  afterwards  applied  to  the  nape  of  the  neck,  and  grain  doses 
of  calomel,  with  some  tartarized  antimony,  were  directed  to  be  taken 
every  six  hours.  On  Monday,  Mr.  Travers  saw  him.  On  the 
morning  of  that  day,  the  eye  had  become  inflamed  for  the  first 
time,  was  greatly  discoloured,  and  tender  on  pressure.  With  the 
right  eye  he  could  only  distinguish  hght  from  darkness  ;  the  vision 
of  the  left  was  rather  obscure. 

Mr.  Travers  concurred  in  the  use  of  calomel  and  antimony,  till 
ptyalism  should  be  produced,  ordered  him  to  be  again  cupped,  and 
recommended  an  opiate  at  night.  In  about  four  days  he  was  sali- 
vated, without  any  amendment  of  sight.  It  was  kept  up  mildly 
till  another  interview  with  Mr.  T.,  when  some  improvement  of 
diet  was  agreed  upon.  On  Thursday  evening,  the  left  eye  became 
dark  to  such  a  degree  that  he  was  unable  to  recognise  his  friends. 


709 

A  consultation  was  now  proposed  with  Dr.  Farre.  At  this  period 
the  right  eye  was  still  much  deeper  coloured  than  natural,  but  no 
appearance  of  inflammation  remained.  The  left  eye  looked  heal- 
thy, but  the  movement  of  the  iris  was  very  indistinct.  Dr.  F, 
regarded  it  as  an  example  of  asthenic  amaurosis,  and  prescribed 
tonics.     At  this  time  the  patient  was  fully  mercurialised. 

Within  a  few  days  after  the  adoption  of  the  tonic  plan,  the  morbid 
colour  of  the  right  eye  disappeared,  and  a  very  shght  motion  was  per- 
ceptible in  the  iris ;  while  the  iris  of  the  left  eye  became  decidedly 
more  sensible  and  mobile.  The  patient's  general  health  improved ; 
the  mercurial  action  decUned ;  and  all  appeared  going  on  well. 
At  this  time,  however,  Mr.  Cooke  was  desired  to  see  a  swelling  on 
the  back,  and  found  an  indolent  carbuncle,  the  size  of  a  walnut,  be- 
tween the  shoulder  and  neck.  This  was  freely  incised  without  pain, 
and  one  or  two  red  pimples  were  observed  on  other  parts  of  the  back. 
In  two  days  one  of  these  pimples  had  extended  very  greatly.  It 
was  seated  near  the  right  scapula,  in  the  fleshy  substance  of  the 
back,  with  extensive  inflammation  of  the  adjacent  parts,  and  a 
dark  vesicle  on  its  surface.  A  deep  incision  relieved  both  the  pain 
and  tension.  At  this  period,  the  21st  of  July,  he  was  using  inter- 
nally a  decoction  and  tincture  of  bark  with  sulphuric  acid.  In  a 
few  days,  it  was  evident  that  the  sensibility  of  both  eyes  had  de- 
creased, especially  that  of  the  left.  The  iris  could  scarcely  be  observed 
to  move,  and  the  membranes  had  become  discoloured  as  those  of  the 
right  were  a  week  before. 

From  this  period,  till  the  termination  of  the  case,  the  treatment 
directed  against  the  carbuncular  action,  which  became  strongly 
manifested,  was  persevered  in,  and  was  occasionally  attended  with 
temporary  improvement  of  the  general  health.  In  addition  to 
tonics  and  nutritious  diet,  he  had  also  at  one  time  small  doses  of 
blue  pill,  and  the  bowels  were  kept  regular  by  mild  laxatives.  On 
the  27th  of  July,  profuse  haemorrhage  occurred  from  the  removal 
of  two  very  loose  teeth  ;  and  on  the  8th  of  August,  diarrhoea  with 
tenesmus,  supervened,  which  was  removed,  in  a  few  days,  by  pro- 
per remedies.  During  this  month,  also,  the  abdomen  was  observed 
to  be  enlarged,  and  on  careful  examination  by  Mr.  C,  at  the  com- 
mencement of  September,  the  liver  and  spleen  were  foimd  of  great 
size,  the  latter  extending  below  the  umbilicus.  In  October,  he 
became  progressively  worse,  and  died  on  the  eighth  of  the  month 
following,  frequent  bloody  and  purulent  discharges  by  stool  having 
occurred  for  several  days  previous  to  dissolution. 

On  examination  after  death,  the  eyes  did  not  present  an  unnatural 
appearance,  except  that  perhaps  there  was  a  little  more  cloudiness  in 
the  pupils  than  usual.  The  scalp  and  dura  mater  adhered  (o  the 
cranium  with  unnatural  firmness,  some  fluid  was  effused  between 
the  membranes  of  the  brain,  and  the  pia  mater  presented  a  highly 
vascular  appearance.  The  optic  nerves  anterior  to  their  union  ap- 
peared of  full  size,  and  healthy  in  texture  ;  but  posteriorly  towards 


710 

the  thalami  they  were  excessively  softened.  The  cerebral  substance 
exhibited  rather  more  numerous  points  of  blood  than  we  find  in  the 
healthy  brain  ;  this  was  more  particularly  manifest  over  the  thai- 
ami  nervorum  opticorum.  and  in  a  greater  degree  on  the  right  than 
on  the  left.  The  right  thalamus  was  greatly  softened  in  texture,  and 
on  its  anterior  surface  the  hning  membrane  appeared  thickened  and 
opaque,  as  if  from  a  deposition  of  lymph.  The  left  thalamus  was 
in  a  similar  state,  though  not  to  an  equal  extent.  The  left  corpus 
straitum  was  unusually  prominent. 

On  opening  the  abdomen,  the  spleen  first  presented  itself  to  view. 
It  weighed  four  pounds  and  a  half,  and  its  surface  was  uniform, 
though  it  contained  a  few  tubercles.  The  liver  was  double  the 
usual  size,  and  indurated,  without  apparent  alteration  of  structure. 
The  mucous  coat  of  the  intestines  was  much  eroded  by  ulceration, 
and  where  that  process  had  not  gone  on,  was  of  a  deep  red  colour. 
The  cavity  of  the  abdomen  contained  about  iwo  pints  of  serous 
fluid.* 

*  Journal  of  Morbid  Anatomy,  Vol.  i.  p.  24.    London,  1828. 


INDEX. 


Abscess  of  anterior  chamber,  405 
of  cornea,  401 
of  orbit,  214 
Abscission  of  iris,  555 
Absorption  of  orbit  from  pressure,  49 

cure  of  cataract  by,  529 
Accidental  colours,  616 
Albino  wants  choroid  pigment,  587 
Albugo,  411 
Amaurosis,  causes  of,  641 

classifications  of,  655 
consequent  to  scarlatina,  670 
consequent  to  suppressed  men- 
ses, 671 
consequent  to  suppressed  per- 
spiration, 673 
consequent  to  suppressed  pur- 
ulent discharge,  673 
definition  of,  637 
diagnosis  of,  649 
from  absorption  of  pigmentum 

nigrum,  591 
from  acute  or  chronic  disor- 
ders of  digestive  organs,  703 
from  aneurism  of  central  arte- 
ry of  retina,  666 
from  aneurism  of  cerebral  ar- 
teries, 664 
from  apoplexy,  664 
from  belladonna,  693 
from  blows  on  eye,  258,  260 
from    cerebral    plethora    and 

congestion,  660 
from  chronic  diarrhcea,  698 
from  concussion  or  other  inju- 
ry of  head,  668 
from  depressed  lens,  499,  509 
from  disease  in  antrum,  701 
from  disease  of  frontal  sinus, 

56 
from  disease  of  lacrymal  or- 
gans, 181 
from  dropsy  of  the  eye,  440, 

442,  444 
from  excessive  venery,  700 
from  exostosis  of  the  orbit,  38 
from  fractured  cranium  with 

depression,  658 
from  inanition  or  debility,  697 
from  inflammation  of  choroid, 

383 
from  inflammation  of  eye,  429 
from  inflammation  of  orbital 

cellular  membrane,  214 
from  inflammation  of  retina, 

389 
from  inflammation  of  internal 
optic  apparatus,   666,   670, 
671,  673 


Amaurosis  from   injuries  of  branches  of 
fifth  pair,  103 
from  intense  light,  666 
from  intoxication,  661 
from  irritation  of  branches  of 

fifth  pair,  700 
from  lightning,  655 
from  masturbation,  700 
from  morbid  changes  affecting 

fifth  pair,  692 
from  morbid  changes  in  optic 
nerves,  678 
from  morbid  changes  in  mem- 
branes or  bones  of  cranium, 
627 
from  morbid  formations  in  brain, 

681 
from  orbital  aneurisms,  249 
from  orbital  exostosis,  38 
from  orbital  tumours,  222 
from  ossification  of  choroid  or 

retina,  431 
from  over  exercise  of  the  sight, 

666 
from  poisons,  833 
from  pressure  on  eye,  257 
from  sanguineous  extravasation 

in  the  head,  658 
from  tobacco,  694,  695 
from  tumour  on  crown  of  head 

and  eyelid,  701 
from  worms,  702  i 

from  wounds  of  eye,  257 
from  wounds  of  eyebrow  or  eye- 
lids, 102 
general  account  of,  637 
illustrations   of  the  species   of, 

658 
its  diagnosis  from  cataract,  472 
actantium,  699 
neuralgia,  673 
prognosis  in,  650 
rheumatica,  673 
seat  of,  638 

stages  and  degrees  of,  649 
symptoms  of,  643 
treatment  of,  650 
with  iritis  after  typhus,  362 
Amblyopia,  637 
Anchylo-blepharon,  416 
Anel's  probe,  uses  of,  193,  194 

syringe,  injections  with,  170 
Aneurism  by  anastomosis  in  orbit,  240 
by  anastomosis  of  eyelids,  127 
of  cerebral  arteries,  a  cause  of 

amaurosis,  664 
of  central  artery  of  retina,  in- 
duces amaurosis,  666 
of  ophthalmic  artery,  247 


712 


Anterior  dvamber,  abscess  of,  405 

osseous  deposit  in,  430 
Antrum,  disease  of,  62 

disease  of,  causing  amaurosis,  701 
Apoplexy,  amaurosis  from,  664 
state  of  pupil  in,  576 
Aqueous  chambers,  abolition  of,  426 
humour,  evacuation  of,  372 
humour,  loss  of,  252 
Aquo-capsulitis,  391 
Arthritic  iritis,  374 
Artificial  eye,  adaptation  of,  433 
pupil,  548 

pupil,  accidents  attending  forma- 
tion of,  573 
pupil,  by  excision,  549 
pupil,  by  incision,  548,  564 
pupil,  by  separation,  549 
pupil,   compound  operations  for, 

572 
pupil,   general  rules   regarding, 

555 
pupil,   states   of  eye   requiring, 
551 
Assalini's  operation  for  artificial  pupil, 568 
Atresia  iridis,  354,  421 
Atrophy  of  eye,  422 

Balls  passing  through  orbit,  18 
Beer's  artificial  pupil  by  incision,  563 

cataract  knife,  514 

classification  of  amauroses,  656 
Bell's  operation  for  cataract,  527 
Belladonna,  amaurosis  from,  693 

uses  of,  358,  502,  552 
Blenorrhcea  of  the  excreting  lacrymal  or- 
gans, 177 
Blepharospasmos,  139 
Blood  effused  into  eye,  446 
Blows  on  eye,  257 

Bonzel's  operation  for  artificial  pupil,  568 
Brain,  morbid   formations  in,    producing 
amaurosis,  681 

partial  loss  of,  in  wounds  of  orbit, 

23 
Buchhorn's  improvement  of  the  operation 

for  cataract,  537 
Burns  of  cornea,  255 

of  eyelids,  98 
Buzzi's  operation  for  artificial  pupil,  568 

Calculus,  lacrymal,  95,  200 
Callosity  of  eyelids,  120 
Cancer  of  eyelids,  121 

of  eyeball,  451 

soft,  of  eyeball,  453 
Carbuncle  of  eyelids,  109 
Caruncula  lacrymalis,  fungus  of,  170 

lacrymalis,  inflammation  of,  169 
lacrymalis,  scirrhus  of,  170 
Capsule,  aqueous,  inflammation  of,  391 

crystalline,  inflamed,  394 
Caries  of  exostosis  of  orbit,  41 

of  fossa  lacrymalis,  34 

of  orbit,  26,  152 

of  OS  unguis,  188 


Cataracta  arborescens,  480 

cystica,  250,  485 

fenestrata,  485 

lymphatica,  355,  486 

pyramidata,  487 

tremulans  vel  natatiUs,  4S5 

traumatica,  256 
Cataract,  471 

anterior  capsular,  481 

bursal,  486 

capsular,  481 

capsulo-lenticular,  483 

causes  of,  476 

central,  483 

classifications  of,  480,  488 

complications  of,  490 

congenital,  485,  489,  495 

couching  of,  498 

cure  of,  by  absorption  or  disso- 
lution, 529 

definition  and  diagnosis  of,  471 

depression  of,  498,  544 

displacement  of,  498,  544 
division  of,  528,  540 

examination  of  cases  of,  475 

extraction  of,  499,  541 

fibrinous,  486 

fluid,  489 

genera  and  species  of,  480 

green,  489,  491 

glasses,  546 

hard,  488   _ 

history  of  pathology  of,  580 

lenticular,- 481 

mixed,  489 

Morgagnian,  483 

pigmentous,  353,  488 

operations  for,  498 

posterior  capsular,  482 

prognosis  in,  478 

purulent,  487 

reclination  of,  498,  544 

sanguineous,  487 

secondary,  544 

siliquose,  485 

soft,  488 

tough,  488 

trabecular,  487 

treatment  of,  without  operation, 
492 

questions  regarding  removal  of, 
by  operation,  494 
Cataracts  from  inflammation,  421 

spurious,  486 

true,  481 
Catarrhal  ophthalmia,  273 
Catarrho-rheumatic  ophthalmia,  342 
Cats-eye,  591 

Cellular  membrane  of  orbit,  infiltration  of,, 
217 
of  orbit,  inflammation 

of,  313 
of   orbit,    scirrhus  of^ 
219 
Celsus  acquainted  with  the  operation  of 
division,  528 


713 


Cerebral  plethora  and  congestion  causing 

amaurosis,  660 
Chemosis,  271,  281 
Cheselden's  operation  for  artificial  pupil, 

548 
Choroid,  ossified,  431 

wounds  of,  ge7 

Choroiditis,  380        ^^' 
Chrupsia,  612 
Coarctation  of  retina,  383 
Coloboma,  101 
Coloured  vision,  612 
Colours,  accidental,  616 

insensibility  to,  609 
Compound  ophthalmise,  399 
Compressibility  of  brain  doubted,  641 
Concussion  of  brain,  a  cause  of  amaurosis, 

668 
Conical  cornea,  437 
Conjunctiva  arida,  165 

foreign  substances  in  folds  of, 

158 
fungus  of,  165 
fungus  of,  from  foreign  bo- 
dies, 159 
granular,  287,  415 
injuries  of,  158 
inflammations  of,  270 
tumours  of,  167 
warts  of,  167 
Conjunctivitis,  in  general,  270 
catarrhalis,  273 
erysipelato  sa,  332 
gonorrhoica,  302 
leucorrhoica,  298 
morbillosa,  336 
phlyctenulosa,  317 
puro-mucous,  272 
puro-mucosa  atmospherica, 

273 
puro-mucosa      contagiosa, 

vel  Egyptiaca,  278 
pustulosa,  318 
scarlatinosa,  336 
scrofulosa,  316 
variolosa,  332 
Corectomia,  566 

Conradi's  operation  for  cataract,  536 
Contusion  of  cornea,  248 
Contusions  on  edge  of  orbit,  2 

of  eyebrow  and  eyelids,  97 
Convulsions  after  wounded  brain  through 
orbit,  8 
of  eyeball,  213 
Cornea,  abscess  of,  401 
bums  of,  255 
conical,  437 
contusion  of.  248 
fistula  of,  40'8 
foreign  substances   adhering    to, 

248 
foreign  substances  imbedded  in, 

349 
hernia  of,  408 
injuries  of,  248 

90 


Cornea,  inflammation  of,  347 

its  mode  of  growth,  412 
lining  membrane  of,  inflamed,  391 
penetrating  wounds  of,  252 
punctured  wounds  of,  251 
rupture  of,  295 
specks  or  opacities  of,  411 
ulcers  of,  407 

and  iris,  staphyloma  of,  423 
Corneitis  scrofulosa,  347 
Corodialysis,  568 
Corotomia,  561 
Couching,  498 
Counter-fractures  of  orbit,  5 
Crampton's  operation  for  entropium,  156 
Cranium,  fractures  of,  4 

membranes  or  bones  of,  diseased, 

producing  amaurosis,  687 
pressure  on  orbit  from  cavity 
of,  69 
Crystalline  lens  and  capsule,  injuries  bf, 
256 

Dacryocystitis  acuta,  171 

chronica,  177 
Daviel's  operation  for  cataract,  512 
Day-blindness,  631 
Debility,  amaurosis  from,  697 
Deformation  of  orbit,  49 
Depression  of  cataract,  498,  499, 501,  544, 
through  cornea,  502 
through    sclerotica, 
502 
Diarrhoea,  chronic,  a  cause  of  amaurosis, 

698 
Digestive  organs,    amaurosis  from  disor- 
ders of,  703 
Dilatation  of  orbit,  49 
Dimple  of  cornea,  408 
Diplopia,  200 
Dislocation  of  eye,  14,  260 

lens,  256 
Displacement  of  cataract,  499,  544 

pupil,  383 
Dissolution  of  vitreous  humour,  422 
Distichiasis,  153 
Distortion  of  eyeball,  211 
Division  of  cataract,  500,  540 

through  cornea,  534 
through  sclerotica,  528 
Donegana's  operation  for  artificial  pupil, 

572 
Double  vision  from  want  of  correspon- 
dence in  muscles  of  eyeball,  204 
Dropsy  of  aqueous  humour,  440 
eye,  440,  445 
vitreous  humour,  444 
subchoroid,  442 
subsclerotic,  442 
Dryness  of  eye,  74 
Ducts,  lacrymal,  injuries  of,  74 
nasal,  exostosis  of,  201 
nasal,  injuries  of,  171 
nasal,  obliteration  of,  201 
nasal,  obstruction  of,  193 


714 


Dura  mater  and  pericranium,   disease  of, 
inducing  amaurosis,  688 

Earl's  instrument,  for  extracting   cataract, 

EcchjTDosis  of  eyelids,  97 

under  conjunctiva,  161 
Ecthyma  cachecticvun  aifecting  iris,  370 
Ectropium,  145 
Etfusion  of  blood  into  eye,  446 
Effusions  into  eyeball,  437 
Emphysema  of  eyelids,  110 

subconjunctival,  161 
Encanthis  benigna,  170 
maligna,  170 
Encysted  tumours  in  orbit,  220 

of  frontal  sinus,  57 
eyehds  and  eyebrows, 
118 
Enlargement  of  lacrymal  gland,  78 
Enlargements  of  eyeball,  437 
Entropium,  154 
Epiphora,  75 
Erysipelas  of  eyelids,  105 
Erj'sipelatous  ophthalmia,  332 
Evacuation  of  aqueous  humour,  393 
Eversion  of  eyelids,  145 
Evulsion  of  eyeball,  261 
Excision,  artificial  pupil  by,  549,  557,  566 
Excrescence  of  iris,  fungous,  450 
Excoriation  of  lower  eyehd,  147 
Exophthalmia,  88,  382 

fungosa,  165 
Exophthalmos,  38,  42,  71,72,  87,  88,  214, 

215,  219,  -240,  247,  384 
Exostosis,  cartilaginous,  of  orbit,  44 
from  maxillary  sinus,  45 
of  orbit,  35,  37 
of  orbit,  carious,  41 
of  nasal  duct,  201 
varieties  of,  37 
Extirpation  of  eyeball,  42,  167,  225,  469 
of  lacrymal  gland,  80 
of  maxillary  fungus,  65 
of  orbital  tumours,  221 
Extraction  of  cataract,  499,  541 

of  cataract,  through   semicir- 
cular incision  of  cornea,  511 
of  cataract,  through  section  of 

one-third  of  cornea,  524 
of  cataract,  through  sclerotica, 
527 
Eye,  adaptation  of  artificial,  433 
apoplexy  of,  445 
blows  on,  257 
gunshot  wounds  of,  260 
modes  of  fixing,  during  operations, 

496 
pressure  on,  257 
saniTuineous  effusion  into,  446 
Eyeball,  atrophy  of,  422 

convulsions  of,  213 
dislocated,  14,  260 
enlargements  of,  437 
evalsioa  of,  261 


Eyeball,  extirpation  of,  42,  167,  225,  46^ 

immovable  distortion  of,  211 

inflammatory  diseases  of,  261  '  '•■ 

injuries  of,  248  ^  i 

melanosis  of,  459 

scirrhus  of,  451 

spongoid,  or  medullary  tumour 
of,  453 

oscillation  of,  211 

tumours  within  its  coats,  437 
Eyebrow,  injuries  of,  97 

wounds  of,  100 
Eyelashes,  false,  153 

inversion  of,  153 
Eyelid,  upper,  falling  down  of,  141 
upper,  palsy  of,  143 
tumour  on,  producing  amaurosis, 

700  _ 
Eyelids,  aneurism  by  anastomosis  of,  127 

bums  and  scalds  of,  98 

callosity  of,  120 

cancer  of,  121 

carbuncle  of,  109 

contusion  and  ecchymosis  of,  97 

emphysema  of,  110 

encysted  tumours  of^  118 

erj'sipelatous    inflammation    of, 
105 

eversion  of,  145 

extirpation  of,  121, 126 

inflammation  of  edges  of,  111 

injuries  of,  97 

inversion  of,  154 

naevus  maternus  of,  127 

oedema  of,  109 

phlegmonous    inflammation    of, 
105 

retraction  of,  144 

spasm  of,  139 

syphilitic  ulceration  of,  126 

twitching  or  quivering  of,  138 

warts  of,  118 

wounds  of,  100 

Far-sightedness,  604 
Fifth  pair,  injuries  of  branches  of,  103 
irritation  of,  inducing  amauro- 
sis, 700 

morbid  changes  of,  inducing 
amaurosis,  692 
neuralgia  of,  142 
Fistula  of  cornea,  407 

of  lacrymal  sac,  185 

of  lachrymal  sac,  spurious,    106j 

107 
true  lacrymal,  94 
Foreign  body  in  orbit,  12,  14 

substances   adhering    to  cornea, 

248 
substances  imbedded  in  cornea, 

249 
substances  in  folds  of  conjunctiva, 
158 
Fractured  cranium  with   depression,    a 
cause  of  amaurosis,  658 


715 


Fractures  of  cranium,  4,  658 
of  edge  of  orbit,  4 
of  walls  of  orbit,  4 
Frontal  sinus,  diseases  of,  induce  amauro- 
sis, 56 
sinus,  encysted  tumours  of,  57 
sinus,  polypus  of,  60 
sinus,  pressure  on  orbit  from,  55 
sinus,  trepanned,  57 
Fungus  hsematodes   of  brain  producing 
amaurosis,  687 
hffimatodes  of  eyeball,  453 
of  antrum,  65 

of  caruncula  lacrymalis,  170 
of  conjunctiva,  165 
of  conjunctiva,  from  foreign  bo- 
dies, 160 

Gibson's  mode  of  extracting  soft  cataracts, 

525 
Gland,  lacrymal,  enlargement  or  scirrhus 
of,  78 
lacrymal,  extirpation  of,  80 
lacrymal,  inflammation  and  sup- 
puration of,  76 
lacrymal,  injuries  of,  73 
lacrymal,    scrofulous  enlargement 

of,  77 
lacrymal,  lacrymal  tumour  in,  86 
Glands  of  cilia,  inflammation  of,  111 
Glasses  for  cataract-patients,  546 
for  long-sightedness^  607 
for  short-sightedness,  600 
periscopic,  600,  608 
Glaucoma,  580 

dissections  of  eyes  in  the  state 

of,  584 
its    diagnosis    from    cataract, 

587 
often  mistaken  for  amaurosis, 
689 
Gonorrhoeal  ophthalmia,  302 
Grando,  117 

Granular  conjunctiva,  287,  415 
Gutta  opaca,  471 
serena,  637 

Hemeralopia,  627,  631 
Hemiopia,  632 
Hernia  of  cornea,  407 
of  iris,  407 
of  lacrymal  sac,  189 
Himly's    operations   for  artificial    pupil, 

547, 568 
Hordeolum,  117 
Hyaloid  membrane  dissolved,  422,  586 

membrane  ossified,  432 
Hydatid  in  brain  producing  amaurosis, 
684 
of  frontal  sinus,  56 
of  lacrymal  gland,  87 
Hydrocephalus,  amaurosis  from,  657,  670 
Hydrops  of  lacrymal  sac,  191 
Hyperostosis  of  orbit,  35 
Hypochyma,  581 
V     Hypopium,  405 


Illusions,  spectral,  624 
Inanition,  amaurosis  from,  697 
Incision,  artificial  pupil  by,  548,  557,  561 
through  cornea,  artificial  pupil 

by,  563 
through  sclerotica,  artificial  pupil 
by,  562 
Infiltration  of  orbital  cellular  membrane, 

217 
Inflammation  of  aqueous  capsule,  391 
bones  of  orbit,  26 
caruncula  lacrymalis,  169 
choroid,  380 
conjunctiva,  270 
cornea,  347 

crystalline  lens  and  cap- 
sule, 394 
•eyelids,  erysipelatous,  105 
eyelids,  phlegmonous  105 
edges  of  eyelids.  111 
excreting  lacrymal  organs, 

acute,  171 
excreting  lacrymal  organs, 

chronic,  177 
frontal  sinuses,  55 
hyaloid  membrane,  347 
internal  optic  apparatus,  a 
cause  of  amaurosis,  666, 
670,671,673 
iris,  350 

lacrymal  gland ,  76 
Meibomian  follicles,  11 1 
orbital  cellular  membrane, 

28,  213 
periosteum  of  orbit,  26 
retina,  386 

semilunar  membrane,  169 
Inflammations  of  eye  from  injuries,  397 
Injections  of  lacrymal  passages,  181 
Injuries  of  branches  of  fifth  pair,  103 
conjunctiva,  158 
cornea, 248 
crystallme  lens  and  capsule, 

256 
eyeball,  248 

eyebrow  and  eyelids,  97 
head,  amaurosis  from,  668 
iris,  255 

lacrymal  canals,  171 
lacrymal  gland  and  ducts,  73 
lacrymal  sac,  171 
muscles  of  eyeball,  202 
nasal  duct,  172 
orbit,  1 
Insensibility  to  certain  colours,  609 
Intermittent  ophthalmia,  400 
Intoxication  inducing  amaurosis,  661 
Inversion  of  eyelashes,  153 

eyelids,  154 
Iris,  fungous  excrescence  of,  450 
hernia  of,  408 
inflammation  of,  350 
injuries  of,  255 
its  motions  eflfected  through  third  pair, 

640 
paralysis  of,  580 


716 


Iris,  preternatural  states  of,  575 

prolapsus  of,  252 

staphyloma  of,  422 

tremulous,  579 
Iritis,  350 

arthritica,  374 

from  ecthyma  cachecticum,  370 

pseudo-syphilitica,  370 

rheumatica,  359 

scrofulosa,  372 

syphilitica,  364 

with  amaurosis  after  typhus,  361 
Irritation  of  branches  of  fifth  pair,  amauro- 
sis from,  700 

Jaeger's  (C.)  operation  forentropivun,  155 
(F.)  operation  for  entropium,  155 
Janin's  operatiou  for  artificial  pupil,  564 

Kepler  explains  eflFects  of  glasses,  599 

Laceration  of  retina,  259 
Lacrymal  calculus,  95,  200 

canals,  injuries  of,  171 
canals,  obstruction  of,  193 
fistula,  true,  94 

gland  and  ducts,  injuries  of,  73 
gland,  enlargement  or  scirrhus 

of,  78 
gland,  extirpation  of,  80 
gland,  inflammation  and  sup- 
puration of,  76 
gland,  lacrymal  tumour  in,  86 
gland,  scrofulous  enlargement 

of,  77 
organs,  acute  inflammation  of 

excreting,  172 
organs,  chronic  inflammation  of 

excreting,  177 
organs,  diseases  of  excreting, 

171 
organs,  diseases  of  secreting,  73 
organs,  diseases  of  induce  amau- 
rosis, 181 
sac,  fistula  of,  185 
sac,  injuries  of,  172 
sac,  hernia  of,  189 
sac,  hydrops  of,  191 
sac,  mucocele  of,  191 
sac,  relaxation  of,  189 
sac,  spurious  fistula  of,  106,  107 
sac,  varix  of,  192 
tumour  in  lacrymal  gland,  86 
tumour  in  subconjunctival  cellu- 
lar membrane,  92 
Lagophthalmos,  33,  144 
Langenbeck  improves  operation  for  artifi- 
cial pupil,  561,  569 
Lapis  divinus,  198 
Lens  and  capsule,  injuries  of,  256 
dislocation  of,  256 
opacity  of,  480 
ossified,  432 
Lentitis,  394 
Leucoma,  412 


Leucorrhoeal  ophthalmia,  298 
Light,  amaurosis  from  intense,  666 
Lippitudo,  116 
Luscitas,  211 

Madarosis,  157 

Marmaryge,  605 

Masturbation,  a  cause  of  amaurosis,  700 

Maunoir's   operation  for  artificial  pupil, 

564 
Maxillary  sinus,  exostosis  from,  44 

sinus,  fungus  or  polypus  of,  65 
sinus,  pressure  on  orbit  from, 

62 
sinus,  pus  in,  62 
Measles,  ophthalmia  from,  336 
Meibomian  apertures,  obliteration  of,  113 
Melanosis  of  eyeball,  459 
Menses,  suppressed,  a  cause  of  amaurosis, 

671 
Mercury  in  iritis,  357 
MUium,  118 

Morbillous  ophthalmia,  336 
Mucocele  of  lacrymal  sac,  191 
Muscae  voUtantes,  621 
Muscles  of  eyeball,   double  vision  from 
want  of  correspondence  in,  204 
of  eyeball,  injuries  of,  202 
of  eyeball,  palsy  of,  203 
Mydriasis,  576 
Myocephalon,  318 
Myopia,  593 
Myosis,  575 

Naevus  maternus  of  eyelids,  127,  240 
Nasal  duct,  exostosis  of,  209 

duct,  injuries  of,  172 

duct,  obstruction  of,  195 
Near-sightedness,  593 
Nebula,  411 
Necrosis  of  orbit,  26 
Neuralgia,  circumorbital,  86 
Neuralgic  amaurosis,  673 
Nictitation,  morbid,  139 
Night-blindness,  627 
Nostril,  pressure  from,  on  orbit,  51 
Nyctalopia,  627,  631 
Nystagmus,  213 

Obliteration  of  pupil,  421 
Obstruction  of  lacrjmial  canals,  193 
nasal  duct,  195 
puncta  lacrymalia,  193 
Oscillation  of  eyeball,  211 
Ocular  spectra,  616 
CEdema  of  eyelid,  109 
Onyx,  401 

Opacities  of  cornea,  411 
Opacity  of  crystalline  capsule,  489 

lens,  481 
Operation  for  anchylo-blepharon,  419 

cataract,  questions  regarding, 

494 
choice  of,  539 
eversion  of  eyelids,  145   147 


w  1  w 


Operation  for  inversion  of  eyelids,  156 

sym-blepharon,  420 
Operations  for  artificial  pupil,  557 
compound,  572 

cataract,  general  account  of,  498 
cataract,  position  of  patient  dur- 
ing, 496 
cataract,   indications  and  con- 
traindications for,  539 
'Ophthalmia  arthritica,  374,  590 
catarrhal,  273 
catarrho-rheumatica,  342 
contagious,  278 
Egyptian,  276,  278 
epidemic,  275 
erysipelatosa,  332 
gonorrhoica,  302 
irritable,  attendant  on  gonor- 
rhoea, 314 
Jeucorrhoica,  298 
morbillosa,  336 
neonatorum,  298 
of  new-born  children,  298 
phlyctenulosa,  317 
porriginosa,  333 
pseudo-syphilitica,  370 
puerperal,  309 
purulent,  278 
purulent  of  infants,  290 
pustulosa,  318 
rheumatica,  337 
scarlatinosa,  336 
scrofulous,  316 
syphilitica,  364 
tarsi.  111 
traumatica,  398 
variolosa,  333 
Ophthalmiae,  261 

classification  of,  264 
compound,  399 
diseases  consequent  to,  401 
intermittent,  400 
remedies  for,  265 
Ophthalmic  artery,  aneurism  of,  247 
Ophthalmo-blenorrhoea,  278 
Optic  nerve,  tumour  encircling,  225 
nerves,  destruction  of,  680 
nerves,  morbid  changes  in  producing 

amaurosis,  678 
nerves,  semi-decussation  of,  632 
nerves,  their  origin  and  connexions, 
637 
Orbicularis  palpebrarum,  palsy  of,  140 
Orbit,  abscess  of,  214 
absorption  of,  49 
caries  of,  26,  152 
counter-fractures  of,  5 
deformation  of,  49 
dilatation  of,  49 
diseases  of,  1 
exostosis  of,  35 
fractures  of,  4 
gunshot  wounds  of,  17 
hyperostosis  of,  35 
incised  wounds  of,  16 


Orbit,  injuries  of,  1 
necrosis  of,  26 
osteo-sarcoma  of,  35 
ostitis  of,  26 

penetrating  wounds  of,  5 
periostitis  of,  26 
periostosis  of,  35 

pressure  on,  from  cavity  of  cranium, 
69 

on,  from  frontal  sinus,  55 
on,  from  maxillary  sinus,  62 
on,  from  nostril,  51 
on,  from  sphenoid  sinus,  69 
on,  from  within  orbit,  51 
tumours  in,  219 
Orbital  aneurisms,  240 

cellular  membrane,  infiltration  of, 

217 
cellular  membrane,    inflammation 

of,  213 
cellular  membrane,  scirrhus  of,  219 
Osseous  deposit  in  anterior  chamber,  430 
Ossification  in  difl:erent  parts  of  eye,  429 
of  choroid,  431 
of  cornea,  430 
of  crystalline  capsule,  432 
of  hyaloid  membrane,  432 
of  lens,  432 
of  retina,  431 
Os  unguis,  caries  of,  188 
Osteo-sarcoma  of  orbit,  35,  47 

Palpebra  ficosa,  415 

Palsy  from  penetrating  wound  of  orbit,  10 
of  levator  palpebrse  superioris,  142 
of  muscles  of  eyeball,  202 
of  orbicularis  palpebrarum,  140 
of  upper  eyelid,  142 
of  upper  eyelid,  from  wounds,  102 
Paralysis  of  iris,  580 
Periostitis  of  orbit,  26 
Periostosis  of  orbit,  35 
Periscopic  glasses,  600,  608 
Perspiration,  suppressed,  causes  amauro- 
sis, 673 
Phlegmon,  subconjunctival,  162 
Phlegmonous  inflammation  of  eyelids,  100 
Phlyctenula  of  eyehds,  118 
Phlyctenular  ophthalmia,  317 
Photophobia,  139 
Photopsia,  614 

infantum  scrofulosa,  140 
Phtheiriasis,  157 
Phthisis  oculi,  422 

Figmentum  nigrum,  amaurosis  from  de- 
ficiency of,  591 
nigrum,  congenitally  deficient 

in  albino,  587 
nigrum  deficient  in  glaucoma, 

_584 
nigrum    removed  by    absorp- 
tion 591 
Pinguecula,  164 

Pituitary  gland  converted  into  cyst  pro- 
ducing amaurosis,  680 


718 


Pladarotes,  414 
Poisons,  amaurosis  from,  693 
Polypus  in  nose  pressing  on  orbit,  51 
of  frontal  sinus,  60 
of  maxillary  sinus,  64 
Porriginous  ophthalmia,  324 
Pott's  operation  for  cataract,  528 
Presbyopia,  604 

Pressure  on  eye,  amaurosis  from,  257 
on  orbit,  effects  of,  49 
on  orbit  from  frontal  sinus,  55 
on  orbit  from  cavity  of  cranium,  69 
on  orbit  from  cavity  of  nostril,  51 
on  orbit  from  sphenoid  sinus,  69 
on  orbit  from  within  orbit,  51 
on  orbit  from  maxillary  sinus,  62 
Prolapsus  of  iris,  252 

operation  of,  469 
Psorophthalmia,  111 
Pterygium,  162 

crassum,  162 
fleshy,  165 
pingue,  164 
tenue,  162 
Ptosis,  140 

Puerperal  ophthalmia,  309 
Puncta  lacrymalia,  obstruction  of,  193 
Pupil,  artificial,  548 

contraction  of,  575 
dilatation  of,  576 
displacement  of,  383 
obliteration  of,  421,  553,  554 
Pupils,  affections  of,   in  compression  of 
the  brain,  659 
contract  during  sleep,  575 
their  occasional  mobility  in  amau- 
rosis explained,  644 
Pustular  ophthalmia,  318 

CLuivering  of  eyelids,  138 

Read's  treatment  of  granular  conjunctiva, 

416 
Reclination  of  cataract,  498,  501,  544 

of  cataract  through  cornea,  502 
of  cataract  through  sclerotica. 
502 
Reisinger's  instrument  for  artificial  pupil, 

569 
Relaxation  of  lacrymal  sac,  189 
Retina,  aneurism  of  its  central  artery,  in- 
duces amaurosis,  666 
coarctation  of,  383 
its  probable  structure,  633 
laceration  of,  259 
ossified,  432 

pressure  on,   by  depressed   lens, 
501,  509 
Retinitis,  386 
Retraction  of  eyelids,  144 
Rheumatic  amaurosis,  673 
iritis,  359 
ophthalmia,  337 
Rupture  of  cornea,  284 

Sarcosis  bulbi,  165 


Scarlatina,  amaurosis  attending,  670 
Scarlatinous  ophthalmia,  336 
Scarpa's  operation  for  artificial  pupil,  549 
Schmidt's  operations  for  artificial  pupil, 

568 
Scirrhus  of  caruncula  lacrymaUa,  170 
of  eyeball,  451 
of  lacrymal  gland,  78 
of  orbital  cellular  membrane,  219 
Sclerotica,  wounds  of,  257 
Sclerotitis  rheumatica  vel  atmospherica, 

337 
Scrofula  affecting  bones  of  orbit,  32,  39 
affecting  conjunctiva,  316 
affecting  excreting  lacrymal  or- 
gans, 179 
affecting  eyehds,  113 
affecting  lacrymal  gland,  77 
affecting  os  unguis,  189 
Scrofulous  corneitis,  347 
iritis,  372 
ophthalmia,  316 
Secondary  cataract,  544 
Semilunar  membrane,    inflammation  of, 

169 
Separation,  artificial  pupil  by,  549,   557, 

568 
Short-sightedness,  593 
Sight,  over-exercise  of,  a  cause  of  amau- 
rosis, 666 
weakness  of,  637 
Small  pox,  ophthalmia  from,  333 
Spasm  of  eyelids,  139 
Speck,  vascular,  318,  411 
Specks  of  cornea,  411 

of  crystalline  capsule  and  lens,  421 
Spectra,  ocular,  616 
Spectral  illusions,  624 
Sphenoid  sinus,  pressure  on  orbit  from,  75 
Spongoid  tumour  of  eyeball,  453 
Squinting,  205 
Staphyloma,  422 

choroid,  382,  429 
conical,  426 
iridis,  422 

morbid  anatomy  of,  426 
of  cornea  and  iris,  423 
operation  for,  427 
partial,  424 
pellucida,  437 
racemosum,  422 
sclerotic,  381,  429 
spherical,  425 
total,  425 
Steatomatous  tumours  in  orbit,  219 
Stiliicidium  lacrymarum,  184 
Strabismus,  205 

convergehs,  205 
divergens,  205 
Style,  use  of  lacrymal,  188 
Suckling,  amaurosis  from,  699 
Suppressed  menses,  amaurosis  from,  671 
perspiration,   amaurosis  from, 

673 
purulent  discharge,  amaurosis 
from,  613 


719 


Sycosis  palpebrse,  415 
Sym-blepharon,  416 
Synchesis,  422 
Synechia  anterior,  421 

posterior,  421 
Synizesis,  421  i 

Syphilis  affecting  bones  of  orbit,  29,  31, 
39 

affecting  os  unguis,  188 
Syphilitic  iritis,  364 

ulceration  of  eyehds,  126 

Tarsal  ophthalmia.  111 
Tears,  morbid,  94 
Tetanus  oculi,  213 
Tic  douloureux,  135 

Tobacco  a  prolific  cause  of  amaurosis,  694 
Trachoma,  415 
Traumatic  ophthalmise,  398 
Tremulous  iris,  579 
Trichiasis,  152 

Tumour,  lacrymal,  in  lacrymal  gland,  86 
lacrymal,  in  subconjunctival  cel- 
lular membrane,  92 
on  crown  of  head  producing  am- 
aurosis, 701 
on  eyelid,  producing  amaurosis, 

700 
spongoid  or  medullary,   of  eye- 
ball, 453 
Tumours,  encysted,  of  eyelids  and  eye- 
brows, 118 
encysted,  of  frontal  sinus,   57 
in  brain,    producing  amauro- 
sis, 681 
in  orbit,  219 
of  conjunctiva,  167 
within  eyeball,  437 
Turpentine,  its  use  in  iritis,  368 
Tylosis,  116 

Ulcers  of  cornea,  407 


Ulcers  of  eyelids,  cancerous,  121 
of  eyelids,  scrofulous,  112 
of  eyelids,  syphilitic,  126 
of  legs,  discharge  from,  suppressed, 
brings  on  amaurosis,  673 

Vaccination,  cure  of  nsevus  maternus  by, 

129 
Varicositas  oculi,  429 
Variolous  ophthalmia,  333 
Venery,  excessive,  a  cause  of  amaurosis, 

700 
Vision,  coloured,  612 

defective,  various  states  of,  593 
Visus  defiguratus,  648 

dimidiatus,  632 

interruptus,  647 

lucidus,  614 

nebulosus,  648 

obliquus,  648 

reticulatus,  648 
Vitreous  humour,  dissolution  of,  423,  585 

Warts  on  eyelids,  118 

of  conjunctiva,  167 
Weakness  of  sight,  637 
Wenzel's  operation  for  artificial  pupil,  549 
Willburg's  operation  for  cataract,  501 
Wollaston    on  semidecussation  of  optic 

nerve,  632 
Worms,  amaurosis  from,  702 
Wounds,  gunshot,  of  orbit,  17 
incised,  of  orbit,  16 
of  choroid,  257 
cornea,  penetrating,  252 
cornea,  punctured,  251 
eye,  gunshot,  260 
eyebrows  and  eyelids,  100 
sclerotica,  257 
penetrating  orbit,  5 

Xeroma,  74 


'\ 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  .date  indicated  beiowor^^ 
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